Guidelines for the conduct of pharmacological clinical trials in hand osteoarthritis: Consensus of a Working Group of the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)

OBJECTIVES

To gather expert opinion on the conduct of clinical trials that will facilitate regulatory review and approval of appropriate efficacious pharmacological treatments for hand osteoarthritis (OA), an area of high unmet clinical need.

METHODS

The European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal diseases (ESCEO) organized a working group under the auspices of the International Osteoporosis Foundation (IOF) and the World Health Organization (WHO).

RESULTS

This consensus guideline is intended to provide a reference tool for practice, and should allow for better standardization of the conduct of clinical trials in hand OA. Hand OA is a heterogeneous disease affecting different, and often multiple, joints of the thumb and fingers. It was recognized that the various phenotypes and limitations of diagnostic criteria may make the results of hand OA trials difficult to interpret. Nonetheless, practical recommendations for the conduct of clinical trials of both symptom and structure modifying drugs are outlined in this consensus statement, including guidance on study design, execution, and analysis.

CONCLUSIONS

While the working group acknowledges that the methodology for performing clinical trials in hand OA will evolve as knowledge of the disease increases, it is hoped that this guidance will support the development of new pharmacological treatments targeting hand OA.

Recommendations for the Registration of Agents to be Used in the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis: Updated Recommendations from the Group for the Respect of Ethics and Excellence in Science

OBJECTIVES

The Group for the Respect and Excellence in Science (GREES) has reviewed and updated their recommendations for clinical trials to evaluate the efficacy and safety of new chemical entities to be used in the treatment and prevention of glucocorticoid-induced osteoporosis (GIOP).

METHODS

Consensus discussion of the committee.

RESULTS

With the exception of steroid use posttransplantation, there is no need to differentiate between underlying diseases. Prevention and treatment for GIOP are dependent on exposure to glucocorticoids rather than T-scores as in postmenopausal osteoporosis (PMO). If fracture data are obtained for PMO, it need not be repeated for GIOP, relying instead on bone mineral density (BMD) trials of at least 1 year. GREES recommends several changes in the previous guidance for GIOP. The committee saw no need to repeat preclinical studies if those have been previously done to assure bone quality in PMO. Similarly, phase I and phase II trials, if careful dose selection has been done for PMO, should not be repeated. The "prevention" and "treatment" claims should remain. Since the most recent evidence suggests significant increase in fracture risk for daily doses of prednisone of 5 mg/day or equivalent, clinical trials should concentrate on patients receiving at least this daily dosage. The emergence of bisphosphonates as the reference treatment, together with the rapid bone loss and high fracture incidence in glucocorticoid users, necessitates recommending a noninferiority trial design with lumbar spine BMD as the primary endpoint after 1 year.

CONCLUSIONS

Registration of new chemical entities to be used in the management of GIOP should be granted, based on a 1-year noninferiority trial, using BMD as primary outcome and alendronate or risedronate as comparator. Demonstration of antifracture efficacy should have been previously demonstrated in PMO.

Differential regulation of chondrocyte metabolism by oncostatin M and interleukin-6

OBJECTIVE

To determine the effects of interleukin (IL)-6 and oncostatin M (OSM) added separately or in combination with IL-1beta on human osteoarthritic (OA) chondrocytes in alginate beads.

DESIGN

Human chondrocytes were isolated from OA cartilage and cultured in alginate beads for 12 days, in the absence or in the presence of increasing amounts of IL-6 (20-500ng/ml) with its soluble receptor or OSM (0.1-10ng/ml) and with or without IL-1beta (1.7ng/ml). Aggrecan (AGG), transforming growth factor-beta1 (TGF-beta1), stromelysin-1 [matrix metalloprotease (MMP)-3], tissue inhibitor of metalloproteinases-1 (TIMP-1), macrophage inflammatory protein-1 beta (MIP-1beta), IL-6 and IL-8 productions were assayed by specific enzyme amplified sensitivity immunoassays. Prostaglandin (PG)E(2) was measured by a specific radioimmunoassay and nitrite (NO(2)(-)) by a spectrophotometric method based upon the Griess reaction.

RESULTS

OSM, but not IL-6, decreased basal AGG and TGF-beta1 synthesis. Although IL-6 stimulated basal TIMP-1 production, it did not significantly modify MMP-3/TIMP-1 ratio. In contrast, 10ng/ml OSM highly increased TIMP-1 production, and decreased by half the ratio MMP-3/TIMP-1. IL-1beta highly stimulated *NO, IL-8, IL-6, MIP-1beta and PGE(2) synthesis but decreased AGG and TGF-beta1 production. Neither IL-6 nor OSM modulated IL-1beta-inhibitory effect on AGG production. IL-6, but not OSM, reversed IL-1beta-induced TGF-beta1 inhibition. At 1-10ng/ml, OSM significantly decreased IL-1beta-stimulated IL-8, MIP-1beta, PGE(2) and *NO production but amplified IL-1beta stimulating effect on IL-6 production. IL-6 had no effect on these parameters.

CONCLUSIONS

OSM and IL-6, two glycoprotein 130 binding cytokines, show different activity profiles on OA chondrocytes, indicating that these cytokines could play different roles in the OA disease process.

Avocado/soybean unsaponifiables increase aggrecan synthesis and reduce catabolic and proinflammatory mediator production by human osteoarthritic chondrocytes

OBJECTIVE

To investigate the effects of avocado (A)/soybean (S) unsaponifiables on the metabolism of human osteoarthritic (OA) chondrocytes cultured in alginate beads over 12 days.

METHODS

Enzymatically isolated OA chondrocytes were cultured in alginate beads in a well defined culture medium for 12 days, in the presence or not of 10-10 M interleukin 1beta (IL-1beta). DNA content was measured using a fluorometric method. Production of aggrecan (AGG), stromelysin-1 (MMP-3), tissue inhibitor of metalloproteinases-1 (TIMP-1), macrophage inflammatory protein-1beta (MIP-1beta), IL-6, and IL-8 were assayed by specific enzyme amplified sensitivity immunoassays. Prostaglandin (PG) E2 was measured by a specific radioimmunoassay and nitrite by a spectrophotometric method based on the Griess reaction. A commercial avocado and soybean mixture of unsaponifiables (A1S2) and each component separately were tested in a range of 0.625 to 40.0 micro g/ml.

RESULTS

After 12 days' incubation, A1S2 increased AGG synthesis and accumulation in alginate beads in a dose and time dependent manner. A1S2 promoted the recovery of aggrecan synthesis after 3 days of IL-1beta treatment. A1S2 was a potent inhibitor of basal and IL-1beta stimulated MMP-3 production. The procedure also weakly reversed the inhibitory effect of IL-1beta on TIMP-1 production. A1S2 inhibited basal production of MIP-1beta, IL-6, IL-8, NO*, and PGE2 by OA chondrocytes and partially counteracted the stimulating effect of IL-1 on PGE2. Compared to avocado or soybean added separately, the mixture had a superior effect on NO* and IL-8 production.

CONCLUSION

A1S2 stimulated aggrecan production and restored aggrecan production after IL-1beta treatment. In parallel, A1S2 decreased MMP-3 production and stimulated TIMP-1 production. These results suggest A1S2 could have structure-modifying effects in OA by inhibiting cartilage degradation and promoting cartilage repair.

Biochemical markers of bone and cartilage remodeling in prediction of longterm progression of knee osteoarthritis

OBJECTIVE

To investigate the relationship between biochemical markers of bone and cartilage remodeling and severity or progression (symptoms and structure) of knee osteoarthritis (OA).

METHODS

Mean and minimal joint space width (JSW) of the femorotibial joint were measured from standardized radiographs taken at baseline and at the end of a 3-year longitudinal study of patients with knee OA. Pain, stiffness, and physical function subscales of the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index were assessed at the same time points. Biochemical markers [serum keratan sulfate (KS), serum hyaluronic acid (HA), urine pyridinoline (PYD) and deoxypyridinoline (DPD), serum osteocalcin (OC), cartilage oligomeric matrix protein (COMP)] were assessed at baseline and after 1 year.

RESULTS

At baseline, no significant correlations were observed between values of biochemical markers and JSW or any of the WOMAC scores. Baseline markers were not correlated with 3-year percentage changes observed in mean or minimal JSW and WOMAC scores. Changes observed after 1 year in OC and HA were significantly correlated with 3-year progression in mean JSW (r = -0.24, p = 0.04 and r = 0.27, p = 0.02, respectively) and in minimal JSW (r = -0.31, p = 0.01 and r = 0.24, p = 0.04, respectively). In patients from the lowest quartile of 1-year changes in HA (< -21.22 ng/ml), mean JSW decreased after 3 years by 0.76 (1.23) mm compared to an increase of 0.11 (0.83) mm in patients in the highest quartile (> +14.34 ng/ml) (p = 0.03).

CONCLUSION

The 3-year radiological progression of knee OA could be predicted by a 1-year increase in OC or a 1-year decrease in HA levels.

Impact of the joint space width measurement method on the design of knee osteoarthritis studies

BACKGROUND AND AIMS

Recent guidelines recommend measurement of articular loss over several years, determined by conventional X-rays, as the principal outcome measure in clinical trials of potential structure-modifying drugs in osteoarthritis (OA). The aim of this study was to assess the impact of the joint space width measurement method on sample size calculation in knee OA studies.

METHODS

Standard knee X-rays were taken in 212 patients with knee OA at baseline and after 3 years of follow-up. Mean joint space width (JSW) was measured with an in-house computer-assisted method. Minimum JSW, measured with a graduated magnifying lens, was taken as external standard. After calculation of the intra- and inter-observer reproducibility of the JSW, sensitivity to change was assessed using the standardized response mean (SRM). The number of patients needed to identify a mean significant difference of 0.5 mm in joint space narrowing between the placebo and the treated group, after 3 years of follow-up, was then calculated.

RESULTS

JSW measured with the computer-assisted technique showed better intra- and inter-observer reproducibility than when using the magnifying lens. JSW values measured with our computer-assisted method were significantly correlated with JSW values obtained using the magnifying lens (r=0.87, p<0.001). The SRM were 0.44 and 0.40 for the computer-assisted method and magnifying lens, respectively. The number of patients needed was 131 per group using the computer-assisted method, and 104 using the magnifying lens.

CONCLUSIONS

Our method of measurement of JSW may be of potential use in longitudinal studies evaluating the effect of structure-modifying drugs in OA, due to its high level of precision and efficiency. However, although sensitivity to change is markedly better with the digitized method compared with the graduated magnifying lens, we recommend the measurement of mean and minimum JSW in structure-modifying OA trials.

Radiologic features poorly predict clinical outcomes in knee osteoarthritis

OBJECTIVES

To assess the impact of radiographic severity and progression on pain and disability.

METHODS

Measurements of mean joint space width (JSW), narrowest join space (NJS) point and assessment of symptoms by the WOMAC questionnaire were performed at baseline and after three years in 212 subjects over 50 years with primary knee OA.

RESULTS

At baseline, JSW and NJS were not significantly correlated with the scores recorded for the WOMAC global index or its pain, stiffness or function subscales. A statistically significant correlation was observed between the joint space narrowing over three years and the changes observed in the pain subscale of the WOMAC during the same period. The three-year changes in the global WOMAC index in patients within the lowest and the highest quartiles of mean joint space width at baseline showed, in both cases, a statistically (p<0.05) significant favorable difference between patients treated with glucosamine sulphate and those having received placebo.

CONCLUSION

Radiographic and clinical progressions of the disease are significantly associated but the clinical relevance of the association is questionable.

Metabolism of human articular chondrocytes cultured in alginate beads. Longterm effects of interleukin 1beta and nonsteroidal antiinflammatory drugs

OBJECTIVES

To investigate the longterm effects (12 days) of nonsteroidal antiinflammatory drugs [NSAID: aceclofenac (ACECLO), sodium diclofenac (DICLO), indomethacin (INDO), nimesulide (NIM), rofecoxib (ROFE), celecoxib (CELE), piroxicam (PIROX), and ibuprofen (IBUP)] on the metabolism of human chondrocytes cultured in alginate beads.

METHODS

Enzymatically isolated osteoarthritic (OA) chondrocytes were cultured in alginate beads in a well defined culture medium for 12 days. The DNA content was measured according to a fluorimetric method and cell proliferation was determined by the incorporation of 3H-thymidine in the newly synthesized DNA. Interleukin 6 (IL-6) and IL-8, stromelysin [matrix metalloproteinase-3 (MMP-3)], and aggrecan (AGG) production were assayed by specific enzyme amplified sensitivity immunoassays, and prostaglandin E2 (PGE2) production by specific radioimmunoassay. All NSAID were tested at the mean peak plasma concentration (Cmax) obtained after oral administration of a therapeutic dose.

RESULTS

In alginate beads, chondrocytes synthesized high amounts of AGG, which were largely (98%) immobilized in the alginate matrix. A large amount (43%) of the IL-8 produced was stored in the alginate beads, whereas almost all IL-6 production (94%) was released in the culture supernatant. At the therapeutic concentration, all NSAID tested fully blocked PGE2 production. ACECLO, DICLO, INDO, NIM significantly inhibited basal and IL-1beta stimulated IL-6 production; CELE and IBUP only inhibited IL-1beta stimulated IL-6 production; and ROFE and PIROX had no significant effects. No NSAID showed significant effects on basal and IL-1beta stimulated IL-8 production, except CELE and IBUP, which slightly increased basal IL-8 production. ACECLO and INDO increased AGG content by 25% in the alginate beads, while the other NSAID were without significant effect. No NSAID were able to modify the inhibitory effect of IL-1beta on AGG production. NSAID did not modify MMP-3 production.

CONCLUSION

The mechanism of action of NSAID seems to be multifactorial and not limited to the inhibition of cyclooxygenases. Further, in our culture conditions, at the Cmax and by comparison with other NSAID, ACECLO and INDO show an advantageous activity profile. They fully blocked PGE2 production, inhibited IL-6 synthesis, and increased aggrecan synthesis. These effects appear advantageous for the longterm treatment of chronic joint diseases such as osteoarthritis.