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1.
Osteoarthritis Cartilage ; 31(2): 279-290, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36414225

RESUMO

OBJECTIVE: Gabapentin can treat neuropathic pain syndromes and has increasingly been prescribed to treat nociplastic pain. Some patients with knee osteoarthritis (OA) suffer from both nociceptive and nociplastic pain. We examined the cost-effectiveness of adding gabapentin to knee OA care. METHOD: We used the Osteoarthritis Policy Model, a validated Monte Carlo simulation of knee OA, to examine the value of gabapentin in treating knee OA by comparing three strategies: 1) usual care, gabapentin sparing (UC-GS); 2) targeted gabapentin (TG), which provides gabapentin plus usual care for those who screen positive for nociplastic pain on the modified PainDETECT questionnaire (mPD-Q) and usual care only for those who screen negative; and 3) universal gabapentin plus usual care (UG). Outcomes included cumulative quality-adjusted life years (QALYs), lifetime direct medical costs, and incremental cost-effectiveness ratios (ICERs), discounted at 3% annually. We derived model inputs from published literature and national databases and varied key input parameters in sensitivity analyses. RESULTS: UC-GS dominated both gabapentin-containing strategies, as it led to lower costs and more QALYs. TG resulted in a cost increase of $689 and a cumulative QALY reduction of 0.012 QALYs. UG resulted in a further $1,868 cost increase and 0.036 QALY decrease. The results were robust to plausible changes in input parameters. The lowest TG strategy ICER of $53,000/QALY was reported when mPD-Q specificity was increased to 100% and AE rate was reduced to 0%. CONCLUSION: Incorporating gabapentin into care for patients with knee OA does not appear to offer good value.


Assuntos
Neuralgia , Osteoartrite do Joelho , Humanos , Osteoartrite do Joelho/terapia , Gabapentina/uso terapêutico , Análise de Custo-Efetividade , Análise Custo-Benefício , Neuralgia/tratamento farmacológico , Neuralgia/etiologia , Anos de Vida Ajustados por Qualidade de Vida
2.
Osteoarthritis Cartilage ; 30(1): 17-31, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34597800

RESUMO

OBJECTIVE: This review outlines the most commonly used quantitative sensory tests to identify pain sensitization. We examine cross-sectional associations between quantitative sensory testing (QST) measures and OA symptoms and severity, along with longitudinal associations between QST findings and response to surgical and non-surgical treatments for OA. DESIGN: We conducted a search in PubMed for English language papers including 'osteoarthritis' and 'quantitative sensory testing' as search terms. Papers that did not pertain specifically to OA or QST were excluded. RESULTS: Pressure Pain Threshold (PPT), Conditioned Pain Modulation (CPM), and Temporal Summation (TS) are the QST measures used most frequently to identify pain sensitization. Findings indicate that persons with knee OA often exhibit lower PPT thresholds, inefficient CPM, and facilitated TS as compared with controls who do not have OA, supporting the discriminant validity of QST. Pre-treatment QST has shown some success in identifying persons who experience less pain relief from surgical and non-surgical treatments for knee OA. Post-treatment QST has shown that sometimes PPT and CPM can normalize (PPT thresholds increase, and CPM becomes efficient) in patients for whom joint replacement is successful. Recent studies indicate that QST measures are more closely associated with pain severity than OA radiographic severity, suggesting that sensitization may be a trait rather than a state. CONCLUSIONS: QST may have a role in identifying persons who are susceptible to chronic pain and may offer an opportunity for personalized, more effective treatment of OA.


Assuntos
Artralgia/diagnóstico , Artralgia/etiologia , Osteoartrite/complicações , Medição da Dor/métodos , Limiar da Dor , Artralgia/terapia , Correlação de Dados , Humanos , Osteoartrite/diagnóstico
3.
Osteoarthritis Cartilage ; 30(1): 10-16, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34023527

RESUMO

Osteoarthritis (OA) is a highly prevalent and disabling condition that affects over 7% of people globally (528 million people). Prevalence levels are even higher in countries with established market economies, which have older demographic profiles and a higher prevalence of obesity, such as the US (14%). As the 15th highest cause of years lived with disability (YLDs) worldwide, the burden OA poses to individuals is substantial, characterized by pain, activity limitations, and reduced quality of life. The economic impact of OA, which includes direct and indirect (time) costs, is also substantial, ranging from 1 to 2.5% of gross national product (GNP) in countries with established market economies. In regions around the world, the average annual cost of OA for an individual is estimated between $700-$15,600 (2019 USD). Though trends in OA prevalence vary by geography, the prevalence of OA is projected to rise in regions with established market economies such as North America and Europe, where populations are aging and the prevalence of obesity is rising.


Assuntos
Efeitos Psicossociais da Doença , Serviços de Saúde/economia , Serviços de Saúde/estatística & dados numéricos , Osteoartrite/economia , Osteoartrite/epidemiologia , Humanos , Prevalência
4.
Osteoarthritis Cartilage ; 30(2): 178-183, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34600120

RESUMO

OBJECTIVE: To identify and summarize literature related to the association between mechanical symptoms (catching and locking of the knee), the presence of meniscal tear, and outcomes after arthroscopic surgery. DESIGN: We searched PubMed and hand-searched reference lists for relevant articles and selected 38 for analysis. RESULTS: Mechanical symptoms appear to have modest sensitivity (ranging 0.32-0.69), specificity (ranging 0.45-0.74) and positive predictive value (ranging 0.75-0.81) for meniscal tear. There is also very little evidence to suggest that those with mechanical symptoms experience better outcomes after arthroscopic surgery. CONCLUSION: Our examination of the literature does not support the hypothesis that mechanical symptoms are related to the presence of meniscal tear or portend better outcomes after arthroscopic surgery.


Assuntos
Lesões do Menisco Tibial/diagnóstico , Artroscopia , Fenômenos Biomecânicos , Humanos , Imageamento por Ressonância Magnética , Avaliação de Sintomas , Lesões do Menisco Tibial/fisiopatologia
5.
Osteoarthritis Cartilage ; 29(1): 28-38, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33171315

RESUMO

OBJECTIVE: Establish the impact of pain severity on the cost-effectiveness of generic duloxetine for knee osteoarthritis (OA) in the United States. DESIGN: We used a validated computer simulation of knee OA to compare usual care (UC) - intra-articular injections, opioids, and total knee replacement (TKR) - to UC preceded by duloxetine in those no longer achieving pain relief from non-steroidal anti-inflammatory drugs (NSAIDs). Outcomes included quality-adjusted life years (QALYs), lifetime medical costs, and incremental cost-effectiveness ratios (ICERs). We considered cohorts with mean ages 57-75 years and Western Ontario and McMaster Osteoarthritis Index (WOMAC) pain 25-55 (0-100, 100-worst). We derived inputs from published data. We discounted costs and benefits 3% annually. We conducted sensitivity analyses of duloxetine efficacy, duration of pain relief, toxicity, and costs. RESULTS: Among younger subjects with severe pain (WOMAC pain = 55), duloxetine led to an additional 9.6 QALYs per 1,000 subjects (ICER = $88,500/QALY). The likelihood of duloxetine being cost-effective at willingness-to-pay (WTP) thresholds of $50,000/QALY and $100,000/QALY was 40% and 54%. Offering duloxetine to older patients with severe pain led to ICERs >$150,000/QALY. Offering duloxetine to subjects with moderate pain (pain = 25) led to ICERs <$50,000/QALY, regardless of age. Among knee OA subjects with severe pain (pain = 55) who are unwilling or unable to undergo TKR, ICERs were <$50,600/QALY, regardless of age. CONCLUSIONS: Duloxetine is a cost-effective addition to knee OA UC for subjects with moderate pain or those with severe pain unable or unwilling to undergo TKR. Among younger subjects with severe pain, duloxetine is cost-effective at WTP thresholds >$88,500/QALY.


Assuntos
Analgésicos/uso terapêutico , Cloridrato de Duloxetina/uso terapêutico , Osteoartrite do Joelho/tratamento farmacológico , Medição da Dor , Idoso , Analgésicos/economia , Analgésicos Opioides/uso terapêutico , Artroplastia do Joelho , Simulação por Computador , Análise Custo-Benefício , Cloridrato de Duloxetina/economia , Glucocorticoides/administração & dosagem , Humanos , Injeções Intra-Articulares , Pessoa de Meia-Idade , Osteoartrite do Joelho/fisiopatologia , Anos de Vida Ajustados por Qualidade de Vida
6.
Osteoarthritis Cartilage ; 28(9): 1154-1169, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32416220

RESUMO

OBJECTIVE: Conduct a systematic review and use meta-analytic techniques to estimate the proportion of total treatment effect that can be attributable to contextual effects (PCE) in adults receiving nonpharmacological, nonsurgical (NPNS) treatments for knee osteoarthritis (OA). DESIGN: We reviewed the published literature to identify five frequently studied NPNS treatments for knee OA: exercise, acupuncture, ultrasound, laser, and transcutaneous electrical nerve stimulation (TENS). We searched for randomized controlled trials (RCTs) of these treatments and abstracted pre- and post-intervention pain scores for groups receiving placebo and active treatments. For each study we calculated the PCE by dividing the change in pain in the placebo group by the change in pain in the active treatment group. We log transformed the PCE measure and pooled across studies using a random effects model. RESULTS: We identified 25 studies for analysis and clustered the RCTs into two groups: acupuncture and topical energy modalities (TEM). 13 acupuncture studies included 1,653 subjects and 12 TEM studies included 572 subjects. The combined PCE was 0.61 (95% CI 0.46-0.80) for acupuncture and 0.69 (95% CI 0.54-0.88) for TEM. CONCLUSION: Our findings suggest that about 61% and 69% of the total treatment effect experienced by subjects receiving acupuncture and TEM treatments, respectively, for knee OA pain may be explained by contextual effects. Contextual effects may include the placebo effect, changes attributable to natural history, and effects of co-therapies. These data highlight the important role of contextual effects in the response to NPNS OA treatments.


Assuntos
Terapia por Acupuntura , Artralgia/terapia , Terapia por Exercício , Terapia a Laser , Osteoartrite do Joelho/terapia , Estimulação Elétrica Nervosa Transcutânea , Terapia por Ultrassom , Artralgia/fisiopatologia , Humanos , Osteoartrite do Joelho/fisiopatologia , Manejo da Dor/métodos , Medição da Dor
7.
Osteoarthritis Cartilage ; 28(6): 735-743, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32169730

RESUMO

OBJECTIVE: Physical activity (PA) in the US knee osteoarthritis (OA) population is low, despite well-established health benefits. PA program implementation is often stymied by sustainability concerns. We sought to establish parameters that would make a short-term (3-year efficacy) PA program a cost-effective component of long-term OA care. METHOD: Using a validated computer microsimulation (Osteoarthritis Policy Model), we examined the long-term clinical (e.g., comorbidities averted), quality of life (QoL), and economic impacts of a 3-year PA program, based upon the SPARKS (Studying Physical Activity Rewards after Knee Surgery) Trial, for inactive knee OA patients. We determined the cost, efficacy, and impact of PA on QoL and medical costs that would make a PA program a cost-effective addition to OA care. RESULTS: Among the 14 million with knee OA in the US, >4 million are inactive. Participation of 10% in the modeled PA program could save 200 cases of cardiovascular disease, 400 cases of diabetes, and 6,800 quality-adjusted life-years (QALYs). The program had an incremental cost-effectiveness ratio (ICER) of $16,100/QALY. Tripling PA program cost ($860/year) raised the ICER to $108,300/QALY; varying QoL benefits from PA yielded ICERs of $8,800/QALY-$99,900/QALY; varying background cost savings from PA did not qualitatively impact ICERs. Offering the PA program to any adults with knee OA (not only inactive) yielded $31,000/QALY. CONCLUSION: A PA program with 3-year efficacy in the knee OA population carried favorable long-term clinical and economic benefits. These results offer justification for policymakers and payers considering a PA intervention incorporated into knee OA care.


Assuntos
Análise Custo-Benefício , Exercício Físico , Osteoartrite do Joelho/economia , Osteoartrite do Joelho/terapia , Qualidade de Vida , Humanos , Modelos Teóricos , Fatores de Tempo , Resultado do Tratamento
8.
Osteoarthritis Cartilage ; 27(4): 571-579, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30465809

RESUMO

In 1992, the Food and Drug Administration (FDA) instituted the accelerated approval regulations that allow drugs or biologics for serious conditions that fill an unmet medical need to be approved on the basis of a surrogate endpoint or an intermediate clinical endpoint. The current definition of a serious condition includes chronic disabling conditions, such as osteoarthritis (OA), and thereby provides expanded opportunities for the use of biomarkers for regulatory approval of drugs for OA. The use of surrogates or intermediate clinical endpoints for initial regulatory approval of a drug or biologic requires confirmation in a post-marketing study of a drug effect on a clinically relevant outcome, such as on how a patient feels, functions or survives. Current FDA guidance requires that the post-marketing approval (PMA) study be ongoing during the time of initial drug approval. This white paper arose out of the need to brainstorm trial designs that might be suitable for PMA of drugs initially approved, on the basis of a surrogate or intermediate clinical endpoint, for treatment of OA to alter disease progression, abnormal function or pathological changes in the morphology of the joint. In this white paper we define the concept and regulations regarding accelerated approval and propose two major study design scenarios for PMA trials in OA. The long-term goal is to discuss and refine these designs in consultation with regulatory agencies in order to facilitate development of drugs to fill the large unmet need in OA.


Assuntos
Produtos Biológicos/farmacologia , Aprovação de Drogas/métodos , Osteoartrite/tratamento farmacológico , Vigilância de Produtos Comercializados , United States Food and Drug Administration , Biomarcadores/metabolismo , Humanos , Osteoartrite/metabolismo , Projetos de Pesquisa , Estados Unidos
9.
Osteoarthritis Cartilage ; 27(10): 1445-1453, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31251985

RESUMO

OBJECTIVE: To examine patterns of prescription opioid use before total joint replacement (TJR) and factors associated with continuous use of opioids before TJR. DESIGN: We conducted an observational cohort study among Medicare enrollees aged ≥65 years who underwent TJR between 2010 and 2014. Preoperative opioid use was defined as having any opioid prescription in the 12-month period before TJR. Patients who had an opioid prescription every month for a 12-month period were defined as continuous users. We examined patients' demographics, pain-related conditions, medication use, other comorbidities, healthcare utilization and their association with use of opioids before TJR. RESULTS: A total of 473,781 patients underwent TJR:,155,516 THR and 318,265 TKR. Among the total cohort, 60.2% patients had any use of opioids and of those, 12.4% used opioids at least once a month continuously over the 12-month baseline period. Correlates of continuous opioid use included African American race (OR = 2.14, 95% confidence intervals (CI) = 2.01-2.28, compared to White patients), history of drug abuse (OR = 5.18, 95% CI = 3.95-6.79) and back pain (OR = 2.32, 95% CI = 2.24-2.39). CONCLUSIONS: In this large cohort of patients undergoing TJR, over 60% ever used opioids and 12.4% of them continuously used opioids in the 12-month prior to surgery. Utilization of opioids became more frequent and high-dosed near the surgery. History of drug abuse, back pain, and African American race were strongly associated with continuous use of opioids preoperatively. Further research is needed to determine short-term and long-term risks of preoperative use of opioids in TJR patients and to optimize pre- and post-TJR pain management of patients with arthritis.


Assuntos
Analgésicos Opioides/uso terapêutico , Artralgia/tratamento farmacológico , Artralgia/etiologia , Artroplastia de Quadril , Artroplastia do Joelho , Prescrições de Medicamentos/estatística & dados numéricos , Osteoartrite do Quadril/complicações , Osteoartrite do Quadril/cirurgia , Osteoartrite do Joelho/complicações , Osteoartrite do Joelho/cirurgia , Cuidados Pré-Operatórios/métodos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Medicare , Estados Unidos
10.
Osteoarthritis Cartilage ; 26(8): 1017-1026, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29758353

RESUMO

OBJECTIVE: Osteoarthritis is one of the leading causes of global disability. Numerous studies have assessed the quality and content of online health information; however, how information content varies between multiple countries remains unknown. The primary objective of this study was to examine how the quality and content of online health information on osteoarthritis compares on an international scale. METHODS: Internet searches for the equivalent of "knee osteoarthritis treatment" were performed in ten countries around the world. For each country, the first ten websites were evaluated using a custom scoring form examining: website type; quality and reliability using the DISCERN and Health-on-the-Net (HON) frameworks; and treatment content based on three international osteoarthritis treatment guidelines. Consistency of search results between countries speaking the same language was also assessed. RESULTS: Significant differences in all scoring metrics existed between countries speaking different languages. Western countries scored higher than more eastern countries, there were no differences between the United States and Mexico in any of the scoring metrics, and HON certified websites were of higher quality and reliability. Searches in different countries speaking the same language had at least 70% overlap. CONCLUSIONS: The quality of online health information on knee osteoarthritis varies significantly between countries speaking different languages. Differential access to quality, accurate, and safe health information online may represent a novel but important health inequality. Future efforts are needed to translate online health resources into additional languages. In the interim, patients may seek websites that display the HON seal.


Assuntos
Osteoartrite/psicologia , Educação de Pacientes como Assunto , Humanos , Internet , Osteoartrite do Joelho/psicologia , Educação de Pacientes como Assunto/métodos , Educação de Pacientes como Assunto/normas
11.
Osteoarthritis Cartilage ; 26(11): 1495-1505, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30092263

RESUMO

OBJECTIVE: We evaluated the cost-effectiveness of Telephonic Health Coaching and Financial Incentives (THC + FI) to promote physical activity in total knee replacement recipients. DESIGN: We used the Osteoarthritis Policy Model, a computer simulation of knee osteoarthritis, to evaluate the cost-effectiveness of THC + FI compared to usual care. We derived transition probabilities, utilities, and costs from trial data. We conducted lifetime analyses from the healthcare perspective and discounted all cost-effectiveness outcomes by 3% annually. The primary outcome was the Incremental Cost-Effectiveness Ratio (ICER), defined as the ratio of the differences in costs and Quality-Adjusted Life Years (QALYs) between strategies. We considered ICERs <$100,000/QALY to be cost-effective. We conducted one-way sensitivity analyses that varied parameters across their 95% confidence intervals (CI) and limited the efficacy of THC + FI to 1 year or to 9 months. We also conducted a probabilistic sensitivity analysis (PSA), simultaneously varying cost, utilities, and transition probabilities. RESULTS: THC + FI had an ICER of $57,200/QALY in the base case and an ICER below $100,000/QALY in most deterministic sensitivity analyses. THC + FI cost-effectiveness depended on assumptions about long-term efficacy; when efficacy was limited to 1 year or to 9 months, the ICER was $93,300/QALY or $121,800/QALY, respectively. In the PSA, THC + FI had an ICER below $100,000/QALY in 70% of iterations. CONCLUSIONS: Based on currently available information, THC + FI might be a cost-effective alternative to usual care. However, the uncertainty surrounding this choice is considerable, and further research to reduce this uncertainty may be economically justified.


Assuntos
Artroplastia do Joelho , Terapia por Exercício/economia , Exercício Físico/fisiologia , Modelos Econômicos , Osteoartrite do Joelho/terapia , Adulto , Idoso , Análise Custo-Benefício , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/fisiopatologia , Período Pós-Operatório , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Tempo
12.
Osteoarthritis Cartilage ; 26(5): 641-650, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29481917

RESUMO

OBJECTIVE: The cost-effectiveness of the recently-introduced generic celecoxib in knee OA has not been examined. METHOD: We used the Osteoarthritis Policy (OAPol) Model, a validated computer simulation of knee OA, to evaluate long-term clinical outcomes, costs, and cost-effectiveness of generic celecoxib in persons with knee OA. We examined eight treatment strategies consisting of generic celecoxib, over-the-counter (OTC) naproxen, or prescription naproxen, with or without prescription or OTC proton-pump-inhibitors (PPIs) to reduce gastrointestinal (GI) toxicity. In the base case, we assumed that annual cost was $130 for OTC naproxen, $360 for prescription naproxen, and $880 for generic celecoxib. We considered a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) and discounted costs and benefits at 3% annually. In sensitivity analyses we varied celecoxib toxicity, discontinuation, cost, and pain level. RESULTS: In the base case analysis of the high pain cohort (WOMAC 50), celecoxib had an incremental cost-effectiveness ratio (ICER) of $284,630/QALY compared with OTC naproxen. Only under highly favorable cost, toxicity, and discontinuation assumptions (e.g., annual cost below $360, combined with a reduction in the cardiovascular (CV) event rates below baseline values) was celecoxib likely to be cost-effective. Celecoxib might also be cost-effective at an annual cost of $600 if CV toxicity were eliminated completely. In subjects with moderate pain (WOMAC 30), at the base case CV event rate of 0.2%, generic celecoxib was only cost-effective at the lowest plausible cost ($190). CONCLUSION: In knee OA patients with no comorbidities, generic celecoxib is not cost-effective at its current price.


Assuntos
Celecoxib/uso terapêutico , Simulação por Computador , Custos de Medicamentos , Medicamentos Genéricos/administração & dosagem , Osteoartrite do Joelho/tratamento farmacológico , Idoso , Celecoxib/economia , Análise Custo-Benefício , Medicamentos Genéricos/economia , Feminino , Humanos , Masculino , Osteoartrite do Joelho/economia , Resultado do Tratamento
13.
Osteoarthritis Cartilage ; 25(5): 667-675, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-27986621

RESUMO

OBJECTIVE: Approximately 20% of total knee arthroplasty (TKA) recipients have suboptimal pain relief. We evaluated the association between pre-surgical widespread body pain and incomplete pain relief following TKA. METHOD: This prospective analysis included 241 patients with knee osteoarthritis (OA) undergoing unilateral TKA who completed questionnaires preoperatively and up to 12 months post-operatively. Questionnaires included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scale and a body pain diagram. We derived the number of non-index painful body regions from the diagram. We used Poisson regression to determine the association between painful body regions identified preoperatively and both WOMAC pain at follow-up and improvement in pain as defined by the minimal clinically important difference (MCID). RESULTS: Mean subject age was 66 years (SD 9), and 61% were females. Adjusting for age, sex, co-morbid conditions, baseline pain, pain catastrophizing, and mental health, we found that more widespread body pain was associated with a higher likelihood of reporting 12-month WOMAC pain score >15 (relative risk [RR] per painful body region 1.39, 95% CI 1.18-1.63) and a greater likelihood of failing to achieve the MCID (RR 1.47, 95% CI 1.16-1.86).). Pain catastrophizing was an independent predictor of persistent pain and failure to improve by the MCID (RR 3.57, 95% CI 1.73-7.31). CONCLUSIONS: Pre-operative widespread pain was associated with greater pain at 12-months and failure to reach the MCID. Widespread pain as captured by the pain diagram, along with the pain catastrophizing score, may help identify persons with suboptimal TKA outcome.


Assuntos
Artroplastia do Joelho/métodos , Dor Musculoesquelética/fisiopatologia , Osteoartrite do Joelho/cirurgia , Medição da Dor , Qualidade de Vida , Centros Médicos Acadêmicos , Idoso , Boston , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/diagnóstico por imagem , Distribuição de Poisson , Cuidados Pré-Operatórios , Prognóstico , Estudos Prospectivos , Índice de Gravidade de Doença , Inquéritos e Questionários , Resultado do Tratamento
14.
Osteoarthritis Cartilage ; 25(6): 850-857, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28043939

RESUMO

OBJECTIVE: Meniscal tears occur frequently in patients with knee osteoarthritis (OA). The aim of our study was to determine whether meniscal damage identified on magnetic resonance imaging (MRI) is associated with the severity of knee pain or the frequency of meniscal symptoms in patients with knee OA. METHODS: We performed a cross-sectional study using data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial. We characterized meniscal damage hierarchically as: root tear; maceration; long and short complex or horizontal tears; and simple tears. Subjects completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Scale and a survey of frequency of meniscal symptoms. We used multivariable general linear models to assess the relationships between meniscal damage and 1) pain severity; and 2) meniscal symptoms, after adjusting for demographic and radiographic features. In further analysis root tear was considered as a binary variable. RESULTS: Analysis included 227 knees. Root tears were present in 19%, maceration in 14%, long complex or horizontal tears in 22%, short complex or horizontal tears in 30%, and simple tears in 14%. Root tears were associated with higher WOMAC pain scores. The adjusted mean WOMAC pain score was 45.2 (standard error (SE) 2.7) for those with root tear and 38.7 (SE 1.2) for subjects without root tear (P = 0.03). We did not find statistically significant associations between meniscal morphology and frequency of meniscal symptoms. CONCLUSION: Root tears were associated with greater pain than meniscal tears or maceration. We did not find a relationship between meniscal damage and meniscal symptoms.


Assuntos
Artralgia/fisiopatologia , Osteoartrite do Joelho/fisiopatologia , Lesões do Menisco Tibial/fisiopatologia , Idoso , Artralgia/etiologia , Estudos Transversais , Feminino , Humanos , Modelos Lineares , Imageamento por Ressonância Magnética , Masculino , Meniscos Tibiais/diagnóstico por imagem , Pessoa de Meia-Idade , Análise Multivariada , Osteoartrite do Joelho/complicações , Osteoartrite do Joelho/diagnóstico por imagem , Medição da Dor , Lesões do Menisco Tibial/complicações , Lesões do Menisco Tibial/diagnóstico por imagem
15.
Osteoporos Int ; 28(1): 239-244, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27421978

RESUMO

This study aims to determine what factors are associated with increased risk of fracture among patients with HIV, in particular whether an important medication used to treat HIV, tenofovir, is associated with fracture. Our study found that while co-infection with hepatitis C and markers of HIV severity were associated with fracture, tenofovir was not. INTRODUCTION: Growing evidence suggests that tenofovir disoproxil fumarate decreases bone density among patients with HIV, but there are conflicting reports as to whether this decrease in bone density translates to higher fracture risk. We aimed to determine what factors were associated with an increased risk of fracture for patients with HIV, in particular whether tenofovir is associated with elevated fracture risk. METHODS: We conducted a retrospective cohort study at two tertiary care hospitals in Boston, MA, between 2001 and 2012 to determine whether tenofovir use is associated with elevated all-site fracture risk, as compared to other antiretroviral medications. We also examined other potential factors associated with fracture among patients with HIV. RESULTS: We identified 1981 HIV-infected patients who had at some point used tenofovir and 682 patients who had not. The mean age was 43 years, and 72 % were male. The hepatitis C co-infection rate was 28 %, about 40 % had nadir CD4 count <200, and about 40 % had a history of an AIDS-defining illness. We did not find an association between risk of fracture and tenofovir disoproxil fumarate (TDF) (adjusted RR (aRR) 0.8, 95 % CI 0.6-1.1). However, co-infection with hepatitis C did increase risk of fracture (aRR 1.6, 95 % CI 1.1-2.3), as did nadir CD4 count <200 (aRR 3.1, 95 % CI 1.9-5.0) and history of AIDS-defining illness (aRR 1.6, 95 % CI 1.1-2.2). CONCLUSION: There was no association found between fracture and tenofovir use, but there were associations between co-infection with hepatitis C and markers of advanced HIV disease and fracture.


Assuntos
Infecções por HIV/complicações , Fraturas por Osteoporose/etiologia , Adulto , Fármacos Anti-HIV/efeitos adversos , Fármacos Anti-HIV/uso terapêutico , Densidade Óssea/efeitos dos fármacos , Contagem de Linfócito CD4 , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Infecções por HIV/fisiopatologia , Hepatite C Crônica/complicações , Hepatite C Crônica/epidemiologia , Humanos , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Fraturas por Osteoporose/epidemiologia , Fraturas por Osteoporose/virologia , Estudos Retrospectivos , Fatores de Risco , Tenofovir/efeitos adversos , Tenofovir/uso terapêutico
16.
Osteoarthritis Cartilage ; 24(4): 593-6, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26555504

RESUMO

OBJECTIVE: We sought to investigate risk perception among an online cohort of younger US adults compared with calculated risk estimates. DESIGN: We recruited a population-based cohort 25-44 years of age with no history of knee osteoarthritis (OA) using Amazon's Mechanical Turk, an online marketplace used extensively for behavioral research. After collecting demographic and risk factor information, we asked participants to estimate their 10-year and lifetime risk of knee OA. We compared perceived risk with risk derived from the OA risk calculator (OA Risk C), an online tool built on the basis of the validated OA Policy Model. RESULTS: 375 people completed the study. 21% reported having 3+ risk factors for OA, 25% reported two risk factors, and 32% reported one risk factor. Using the OA Risk C, we calculated a mean lifetime OA risk of 25% and 10-year risk of 4% for this sample. Participants overestimated their lifetime and 10-year OA risk at 48% and 26%, respectively. We found that obesity, female sex, family history of OA, history of knee injury, and occupational exposure were all significantly associated with greater perceived lifetime risk of OA. CONCLUSIONS: Risk factors are prevalent in this relatively young cohort. Participants consistently overestimated their lifetime risk and showed even greater overestimation of their 10-year risk, suggesting a lack of knowledge about the timing of OA onset. These data offer insights for awareness and risk interventions among younger persons at risk for knee OA.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Osteoartrite do Joelho/etiologia , Adulto , Estudos de Coortes , Feminino , Humanos , Masculino , Osteoartrite do Joelho/epidemiologia , Osteoartrite do Joelho/psicologia , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Estados Unidos/epidemiologia
18.
Osteoarthritis Cartilage ; 24(6): 962-72, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26844640

RESUMO

OBJECTIVE: Summarize the comparative effectiveness of oral non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in reducing knee osteoarthritis (OA) pain. METHODS: Two reviewers independently screened reports of randomized controlled trials (RCTs), published in English between 1982 and 2015, evaluating oral NSAIDs or opioids for knee OA. Included studies were at least 8 weeks duration, conducted in Western Europe, the Americas, New Zealand, or Australia, and reported baseline and follow-up pain using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain subscale (0-100, 100-worst). Effectiveness was evaluated as reduction in pain, accounting for study dropout and heterogeneity. RESULTS: Twenty-seven treatment arms (nine celecoxib, four non-selective NSAIDs [diclofenac, naproxen, piroxicam], eleven less potent opioids [tramadol], and three potent opioids [hydromorphone, oxycodone]) from 17 studies were included. NSAID and opioid studies reported similar baseline demographics and efficacy withdrawal rates; NSAID studies reported lower baseline pain and toxicity withdrawal rates. Accounting for efficacy-related withdrawals, all drug classes were associated with similar pain reductions (NSAIDs: -18; less potent opioids: -18; potent opioids: -19). Meta-regression did not reveal differential effectiveness by drug class but found that study cohorts with a higher proportion of male subjects and worse mean baseline pain had greater pain reduction. Similarly, results of the network meta-analysis did not find a significant difference in WOMAC Pain reduction for the three analgesic classes. CONCLUSION: NSAIDs and opioids offer similar pain relief in OA patients. These data could help clinicians and patients discuss likely benefits of alternative analgesics.


Assuntos
Dor , Analgésicos Opioides , Anti-Inflamatórios não Esteroides , Austrália , Europa (Continente) , Humanos , Nova Zelândia , Osteoartrite do Joelho
19.
Osteoarthritis Cartilage ; 24(5): 776-85, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-26746146

RESUMO

OBJECTIVE: Studies suggest nerve growth factor inhibitors (NGFi) relieve pain but may accelerate disease progression in some patients with osteoarthritis (OA). We sought cost and toxicity thresholds that would make NGFi a cost-effective treatment for moderate-to-severe knee OA. DESIGN: We used the Osteoarthritis Policy (OAPol) model to estimate the cost-effectiveness of NGFi compared to standard of care (SOC) in OA, using Tanezumab as an example. Efficacy and rates of accelerated OA progression were based on published studies. We varied the price/dose from $200 to $1000. We considered self-administered subcutaneous (SC) injections (no administration cost) vs provider-administered intravenous (IV) infusion ($69-$433/dose). Strategies were defined as cost-effective if their incremental cost-effectiveness ratio (ICER) was less than $100,000/quality-adjusted life year (QALY). In sensitivity analyses we varied efficacy, toxicity, and costs. RESULTS: SOC in patients with high levels of pain led to an average discounted quality-adjusted life expectancy of 11.15 QALYs, a lifetime risk of total knee replacement surgery (TKR) of 74%, and cumulative discounted direct medical costs of $148,700. Adding Tanezumab increased QALYs to 11.42, reduced primary TKR utilization to 63%, and increased costs to between $155,400 and $199,500. In the base-case analysis, Tanezumab at $600/dose was cost-effective when delivered outside of a hospital. At $1000/dose, Tanezumab was not cost-effective in all but the most optimistic scenario. Only at rates of accelerated OA progression of 10% or more (10-fold higher than reported values) did Tanezumab decrease QALYs and fail to represent a viable option. CONCLUSIONS: At $100,000/QALY, Tanezumab would be cost effective if priced ≤$400/dose in all settings except IV hospital delivery.


Assuntos
Anti-Inflamatórios não Esteroides/economia , Anticorpos Monoclonais Humanizados/economia , Custos de Medicamentos/estatística & dados numéricos , Fator de Crescimento Neural/antagonistas & inibidores , Osteoartrite do Joelho/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anti-Inflamatórios não Esteroides/administração & dosagem , Anti-Inflamatórios não Esteroides/efeitos adversos , Anti-Inflamatórios não Esteroides/uso terapêutico , Anticorpos Monoclonais Humanizados/administração & dosagem , Anticorpos Monoclonais Humanizados/uso terapêutico , Análise Custo-Benefício , Progressão da Doença , Feminino , Custos de Cuidados de Saúde , Pesquisa sobre Serviços de Saúde/métodos , Humanos , Infusões Intravenosas , Injeções Subcutâneas , Masculino , Pessoa de Meia-Idade , Modelos Econométricos , Osteoartrite do Joelho/economia , Medição da Dor/métodos , Anos de Vida Ajustados por Qualidade de Vida , Autoadministração/economia , Estados Unidos
20.
Osteoarthritis Cartilage ; 24(12): 2077-2081, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27497697

RESUMO

OBJECTIVE: To evaluate the internal consistency and construct validity of the Physical Function short-forms for the Hip and Knee Injury Osteoarthritis Outcome Scores (HOOS-PS/KOOS-PS) and the Intermittent and Constant Osteoarthritis Pain (ICOAP) in a nine country study of patients consulting for total hip or knee replacement (THR or TKR). METHODS: Patients completed HOOS-PS or KOOS-PS, ICOAP and Western Ontario and McMaster Universities' Osteoarthritis Index (WOMAC) pain and physical function subscales at their consultation visit. Internal consistency was calculated using Cronbach's alpha. The association of HOOS-PS/KOOS-PS and ICOAP with WOMAC pain and function subscales was calculated with Spearman correlation coefficients with 95% confidence intervals. RESULTS: HOOS-PS/KOOS-PS and ICOAP demonstrated high internal consistency across countries (alpha 0.75-0.96 (hip) and 0.76-0.95 (knee)). Both HOOS-PS and KOOS-PS demonstrated high correlations (0.76-0.90 and 0.75-0.91, respectively) with WOMAC function in all countries. ICOAP exhibited moderate to high correlations with WOMAC pain and function subscales (0.53-0.84 (hip) and 0.43-0.84 (knee)). CONCLUSION: The psychometric properties of the HOOS-PS/KOOS-PS, and ICOAP were maintained across all countries.


Assuntos
Osteoartrite do Joelho , Comparação Transcultural , Avaliação da Deficiência , Humanos , Osteoartrite do Quadril , Medição da Dor , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Inquéritos e Questionários
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