The prevalence, incidence and management of low back pain with radiating leg pain in Dutch general practice: A population-based cohort study in the Rijnmond Primary Care Database.

BACKGROUND: Radiating leg pain is common in patients with low back pain (LBP). In this study, we aimed to determine the prevalence and incidence of LBP with radiating leg pain in Dutch general practice, and to describe the prescribed medications and requested imaging diagnostics. METHODS: The Rijnmond Primary Care Database containing over 500,000 primary care patients was used to select patients ≥18 years with LBP with radiating leg pain between 2013 and 2021. Data on patient characteristics, LBP episodes, prescribed medication and requested imaging in the first 3 months of an episode was extracted. Descriptive statistics were used to present patient characteristics and diagnostic/therapeutic interventions. RESULTS: A total of 27,695 patients were included. The total number of LBP with radiating leg pain episodes in these patients was 36,268. In 2021, the incidence and prevalence were 19.1 and 25.7 per 1000 patient years, respectively. In 60% of patients, the episode duration was shorter than 1 month. In 62% of the episodes, patients visited the general practitioner (GP) one to two times. In 59% of the episodes, at least one medication was prescribed, non-steroidal anti-inflammatory drugs (NSAIDs) being the most common one (45%). In approximately 11% of the episodes, additional diagnostic imaging was requested. CONCLUSION: LBP with radiating leg pain is common in Dutch general practice patients. About 2/3rd were prescribed pain medications. Dutch request few to none diagnostic imaging for these patients which is in line with clinical practice guidelines. SIGNIFICANCE: In this new study, we have gained insights into the incidence and prevalence of LBP with radiating leg pain in Dutch general practice. Both remained fairly stable over the study period of 9 years (2013-2021). Overall, the care burden regarding seeking contact with the GPs and the requested diagnostics seem not to be that high. In 62% of the care episodes, there were one or two consultations with the GP, and in 11% of the episodes a diagnostic imaging was requested. Pain medications frequently prescribed (i.e. 2/3rd of the episodes), with NSAIDs being the most common ones.

No Added Value of Duloxetine in Patients With Chronic Pain due to Hip or Knee Osteoarthritis: A Cluster-Randomized Trial.

OBJECTIVE: To assess the effectiveness of duloxetine in addition to usual care in patients with chronic osteoarthritis (OA) pain. The cost-effectiveness and whether the presence of symptoms of centralized pain alters the response to duloxetine were secondary objectives. METHODS: We conducted an open-label, cluster-randomized trial. Patients with chronic hip or knee OA pain who had an insufficient response to acetaminophen and nonsteroidal antiinflammatory drugs were included. Randomization took place at the general practice level, and patients received duloxetine (60 mg/day) in addition to usual care or usual care alone. The presence of centralized pain was defined as a modified PainDETECT Questionnaire score >12. The primary outcome measure was Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores (scale 0-20) at 3 months after the initiation of treatment. Our aim was to detect a difference between the groups of a clinically relevant effect of 1.9 points (effect size 0.4). We used a linear mixed model with repeated measurements to analyze the data. RESULTS: In total, 133 patients were included, and 132 patients were randomized into treatment groups. A total of 66 patients (at 31 practices) were randomized to receive duloxetine in addition to usual care, and 66 patients (at 35 practices) were randomized to receive usual care alone. We found no differences in WOMAC pain scores between the groups at 3 months (adjusted difference -0.58 [95% confidence interval (95% CI) -1.80, 0.63]) or at 12 months (adjusted difference -0.26 [95% CI -1.86, 1.34]). In the subgroup of patients with centralized pain symptoms, we also found no effect of duloxetine compared to usual care alone (adjusted difference -0.32 [95% CI -2.32, 1.67]). CONCLUSION: We found no effect of duloxetine added to usual care compared to usual care alone in patients with chronic knee or hip OA pain. Another trial including patients with centralized pain symptoms should be conducted to validate our results.

Incidence and Prevalence of Knee Osteoarthritis Using Codified and Narrative Data From Electronic Health Records: A Population-Based Study.

OBJECTIVE: To determine the incidence and prevalence of knee osteoarthritis (OA) using codified and narrative data from general practices throughout The Netherlands. METHODS: This retrospective cohort study was conducted using the Integrated Primary Care Information database. Patients with codified knee OA were selected, and an algorithm was developed to identify patients with narratively diagnosed knee OA only. Point prevalence proportions and incidence rates among people age ≥30 years were assessed from 2008 to 2019. The association of comorbidities with codified knee OA was analyzed using multivariable logistic regression. RESULTS: The positive predicted value of narratively diagnosed knee OA only was 94.0% (95% confidence interval [95% CI] 87.4-100%) and for codified knee OA 96.0% (95% CI 90.6-100%). Including narrative data in addition to codified data resulted in a prevalence 1.83-2.01 times higher (over the study years); prevalence increased from 5.8% to 11.8% between 2008 and 2019. The incidence rate was 1.93-2.28 times higher and increased from 9.98 per 1,000 person-years to 13.8 per 1,000 person-years between 2008 and 2019. Among patients with codified knee OA, 39.4% were previously diagnosed narratively with knee OA, on average ~3 years earlier. Comorbidities influenced the likelihood of being recorded with codified knee OA. CONCLUSION: Our study of a Dutch primary care database showed that current incidence and prevalence estimates based on codified data alone from electronic health records are underestimated. Narrative data can be incorporated in addition to codified data to identify knee OA patients more accurately.

Antidepressant and anticonvulsant prescription rates in patients with osteoarthritis: a population-based cohort study.

OBJECTIVES: There are signs that antidepressants and anticonvulsants are being prescribed more often for OA patients, despite limited evidence. Our objectives were to examine prescription rates and time trends for antidepressants and anticonvulsants in OA patients, to assess the percentage of long-term prescriptions, and to determine patient characteristics associated with antidepressant or anticonvulsant prescription. METHODS: A population-based cohort study was conducted using the Integrated Primary Care Information database. First, episodic and prevalent prescription rates for antidepressants (amitriptyline, nortriptyline and duloxetine) and anticonvulsants (gabapentinoids) in OA patients were calculated for the period 2008-17. Logistic regression was used to assess which patient characteristics were associated with prescriptions. RESULTS: In total, 164 292 OA patients were included. The prescription rates of amitriptyline, gabapentin and pregabalin increased over time. The increase in prescription rates for pregabalin was most pronounced. Episodic prescription rate increased from 7.1 to 13.9 per 1000 person-years between 2008 and 2017. Amitriptyline was prescribed most (15.1 episodic prescriptions per 1000 person-years in 2017). Prescription rates of nortriptyline and duloxetine remained stable at 3.0 and 2.0 episodic prescriptions per 1000 person-years, respectively. For ≤3% of patients with incident OA, medication was prescribed long-term (≥3 months). In general, all medication was prescribed more frequently for older patients (except duloxetine), women, patients with OA in ≥2 joints, patients with spinal OA and patients with musculoskeletal disorders. CONCLUSION: Prescription rates of amitriptyline, gabapentin and pregabalin increased over time. Since there is little evidence to support prescription in OA, caution is necessary when prescribing.

Opioid prescriptions in patients with osteoarthritis: a population-based cohort study.

OBJECTIVES: To examine the incidence, prevalence and trends for opioid prescriptions in patients with OA. Furthermore, types of opioids prescribed and long-term prescription rates were examined. Finally, the patient characteristics associated with the prescription of opioids were assessed. METHODS: A population-based cohort study was conducted using the Integrated Primary Care Information database. Incidence and prevalence of opioid prescriptions were calculated for the period 2008-2017. Logistic regression was used to assess which patient characteristics were associated with opioid prescriptions. RESULTS: In total, 157 904 OA patients were included. The overall prescription rate remained fairly stable, at around 100 incident and 170 prevalent prescriptions per 1000 person years. However, the incident prescription rate for oxycodone increased from 7.1 to 40.7 per 1000 person years and for fentanyl from 4.2 to 7.4 per 1000 person years. The incident prescription rate for paracetamol/codeine decreased from 63.0 to 13.3 per 1000 person years. Per follow-up year, long-term use was found in 3% of the patients with incident OA. Finally, factors associated with more prescriptions were increasing age, OA in ≥2 joint groups [odds ratio (OR) 1.56; 95% CI: 1.51, 1.65] and the presence of other musculoskeletal disorders (OR 4.91; 95% CI: 4.76, 5.05). Men were less likely to be prescribed opioids (OR 0.78; 95% CI: 0.76, 0.80). CONCLUSION: Prescription rates for opioids remained stable, but types of opioids prescribed changed. Oxycodone and fentanyl were increasingly prescribed, while prescriptions of paracetamol/codeine decreased. Since the benefit of opioids for OA pain is questionable and side effects are common, opioids should be prescribed with caution.

Analgesic Use in Dutch Patients With Osteoarthritis: Frequent But Low Doses.

OBJECTIVE: The aim of this study was to examine which analgesics are used by patients with osteoarthritis (OA)-related pain and how the analgesics are used in the preceding month. In addition, their beliefs about (pain) medication and the rationale of those declining to use analgesics were explored. METHODS: An online cross-sectional survey was sent to 1521 patients participating in the panel of the Dutch Arthritis Foundation. Descriptive analyses and logistic regression were used to analyze data. RESULTS: Of the 842 participants (56%) with OA that responded, 70% had generalized OA, 26% had concomitant fibromyalgia, and 34% had another musculoskeletal morbidity. Of all participants, 71% used analgesics, and 34% used more than 1 type. Analgesics were used for more than 14 days in the preceding month by most participants, with paracetamol being used most frequently (51%). Doses used were predominantly lower than the daily defined dose: 58.2% for paracetamol, 31.2% for nonsteroidal anti-inflammatory drugs/cyclooxygenase-2 inhibitors, and 75.7% for weak opioids. Compared with participants with concomitant fibromyalgia or other musculoskeletal morbidities, participants with OA alone significantly more frequently declined to use analgesics (p < 0.01) and significantly less frequently used 2 or 3 types of analgesics (p < 0.05). CONCLUSIONS: In this population with generalized OA and musculoskeletal comorbidities, medication use was high, and more than 1 type of analgesic was frequently used. Patients with concomitant fibromyalgia or other musculoskeletal morbidities more frequently used 2 or 3 types of analgesics; however, this use was often intermittent and in low doses. Medication use on a daily basis and at higher doses may lead to improved analgesic effect.

Effectiveness and cost-effectiveness of duloxetine added to usual care for patients with chronic pain due to hip or knee osteoarthritis: protocol of a pragmatic open-label cluster randomised trial (the DUO trial).

INTRODUCTION: Osteoarthritis (OA) is a highly prevalent painful condition of the musculoskeletal system. The effectiveness of current analgesic options has proven to be limited and improved analgesic treatment is needed. Several randomised placebo-controlled trials have now demonstrated the efficacy of duloxetine, an antidepressant with a centrally acting effect, in the treatment of OA pain. The aim of the current study is to investigate if duloxetine is effective and cost-effective as a third-choice analgesic added to usual care for treating chronic pain compared with usual care alone in general practice. METHODS AND ANALYSIS: A pragmatic open, cluster randomised trial is conducted. Patients with pain due to hip or knee OA on most days of the past 3 months with insufficient benefit of non-steroidal anti-inflammatory drugs or contraindications or intolerable side effects are included. General practices are randomised to either (1) duloxetine and usual care or (2) usual care only. Primary outcome is pain at 3 months measured on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale. Secondary outcomes at 3 months and 1 year are pain (WOMAC, at 1 year), function (WOMAC), adverse reactions, quality of life and modification of the response to treatment by the presence of centrally sensitised pain (modified PainDETECT). At 1 year, medical and productivity costs will be assessed. Analyses will be performed following the intention-to-treat principle taking the cluster design into account. ETHICS AND DISSEMINATION: The study is approved by the local Medical Ethics Committee (2015-293). Results will be published in a scientific peer-reviewed journal and will be communicated at conferences. TRIAL REGISTRATION NUMBER: Dutch Trial Registry(ntr4798); Pre-results.

Amitriptyline for musculoskeletal complaints: a systematic review.

Background: The role of amitriptyline in musculoskeletal pain is not as clearly defined as in classical neuropathic pain conditions. Objective: To assess the efficacy and effectiveness of amitriptyline in the treatment of pain in musculoskeletal complaints. Methods: An extensive search (including Medline, Embase and Web of Science) was made up to April 2016 for randomised controlled trials on amitriptyline in musculoskeletal complaints compared to placebo, usual care, or other analgesic use. Included studies were assessed for risk of bias. Outcomes of interest were pain reduction and function improvement. Results: Of the 2066 articles identified, seven were finally included. These studies were performed in patients with low back pain (4), rheumatoid arthritis (2), and patients with arm pain from repetitive use (1). No meta-analysis was performed due to clinical heterogeneity of the studies. Two studies with low risk of bias found positive results. One study found that 50 mg/day of amitriptyline [Visual Analogue Scale (VAS) -3.9 points] resulted in a significantly greater reduction in pain than treatment with pregabalin 600 mg/day (VAS -2.9 points) and improved function (improvement on the Oswestry Disability Index >20%: 65% versus 49.5%). Amitriptyline improved function in arm pain compared to placebo (Upper Extremity Function Scale: -3.9 versus 0.8). A similar amount of side-effects occurred in the amitriptyline and the comparison groups. Conclusion: Few studies have evaluated the use of amitriptyline in musculoskeletal complaints. Although amitriptyline may be effective in musculoskeletal complaints, more studies are required to establish for whom amitriptyline works better than other analgesics.