Abstract
BackgroundSome osteoarthritis (OA) patients experience inadequate pain relief from analgesics like acetaminophen and nonsteroidal anti-inflammatory drugs. This could be the result of experienced non-nociceptive centralized pain. Placebo-controlled randomized trials (RCT) have proven the effectiveness of duloxetine for OA and several chronic pain conditions where central sensitization (CS) is one of the key underlying pain mechanisms.ObjectivesAssess the efficacy of an 8-week duloxetine treatment compared to usual care in end-stage knee and hip OA patients with a level of centralized pain.DesignPragmatic, enriched, open-label RCT.MethodsPatients were randomized to duloxetine or to care-as-usual. Primary outcome was pain in the index joint, measured with the pain domain of the Knee injury and Osteoarthritis Outcome Score (KOOS) or the Hip disability and Osteoarthritis Outcome Score (HOOS). The intention-to-treat principle was used, with mixed-model repeated measures to analyze the effect.ResultsOne hundred eleven patients were randomized. Nearly 44% felt much to very much better after duloxetine usage compared to 0% in the care-as-usual group (p < 0.001). The duloxetine group scored 11.3 points (95%CI: 5.8, 16.8) better on the pain domain of the KOOS/HOOS (p < 0.001). Knee patients improved significantly more than hip patients (18.7 [95%CI: 11.3, 26.1] versus 6.0 [95%CI: − 2.6, 14.5] points better).ConclusionsAdding duloxetine treatment seems to be beneficial for end-stage knee OA patients with neuropathic-like symptoms (at risk of CS). End stage Hip OA patients seem to be nonresponsive to duloxetine.Trial registrationDutch Trial Registry with number NTR 4744 (15/08/2014) and in the EudraCT database with number 2013–004313-41.
Highlights
Some osteoarthritis (OA) patients experience inadequate pain relief from analgesics like acetami‐ nophen and nonsteroidal anti-inflammatory drugs
Adding duloxetine treatment seems to be beneficial for end-stage knee OA patients with neuropathiclike symptoms
End stage Hip OA patients seem to be nonresponsive to duloxetine
Summary
Some osteoarthritis (OA) patients experience inadequate pain relief from analgesics like acetami‐ nophen and nonsteroidal anti-inflammatory drugs. This could be the result of experienced non-nociceptive central‐ ized pain. It is known that some patients do not experience adequate pain relief from first-line treatment modalities like acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) [2]. This ineffectiveness probably arises from OA-related mechanopathology and the biological response to mechanically induced injury, which likely differs per individual [3]. This could lead to hyperexcitability of the peripheral and the central nervous system (central sensitization [CS]) [4,5,6]
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