Research Review by Dr. Shawn Thistle©

Date:

Dec. 2004

Study Title:

Non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2-inhibitors, in osteoarthritic knee pain: meta-analysis of randomized placebo controlled trials

Authors:

Bjordal JM, Ljunggren AE, Klovning A, Slordal L

Publication Information:

British Medical Journal 2004

Summary:

Osteoarthritis of the knee is a common and potentially disabling condition. This condition is associated with pain, swelling, loss of range of motion, impaired muscular stability, and functional disability. It has become customary, and is reflected in many clinical practice guidelines, to include non-steroidal anti-inflammatory medications (NSAIDs, including the newer "COX-2 Inhibitor" drugs) in the treatment of this condition.

In this study, a meta-analysis was performed to estimate the analgesic effect (that is, pain relief) of NSAIDs in patients with osteoarthritis of the knee. 23 randomized, placebo controlled trials including more than 10 000 patients were included in the analysis.

The overall quality of the studies was acceptable, but some notable, and concerning flaws were noted including:
  1. only 8 studies adequately described randomization procedure, concealment of group allocation, and patient/doctor blinding procedures
  2. some studies required that patients have a certain increase in symptoms after discontinuing NSAID use to be included in the study - obviously this would inflate the results of a trial in favour of the drug
  3. similarly, some trials excluded patients known to not respond to NSAIDs, also creating a bias in favour of the NSAIDs

Conclusions & Practical Application:

After analyzing and combining the 23 studies the authors arrived at the following conclusions and recommendations:
  1. NSAIDs have been shown to provide short-term pain relief for knee osteoarthritis
  2. long term use of NSAIDs in the treatment of knee OA cannot be recommended at this time
There is a current trend of widespread and long-term use of NSAIDs for osteoarthritis, primarily in elderly patients (as they are most likely to have OA in the first place!). This degree of use is associated with considerable side effects such as gastrointestinal bleeding and ulcers, increased blood pressure, development of congestive heart failure, and in the case of the recently withdrawn Vioxx, other cardiovascular complications.

Responsible practitioners should incorporate evidence from reviews such as this to limit the intake of oral NSAID medications to short-term trials of therapy in patients with knee OA.

Patients should be discouraged from chronic intake of these drugs, and encouraged to seek more conservative forms of treatment that are gaining support in the scientific literature, such as medical acupuncture.