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Meta-Analysis
. 2014 Mar 11:15:76.
doi: 10.1186/1471-2474-15-76.

The efficacy of duloxetine, non-steroidal anti-inflammatory drugs, and opioids in osteoarthritis: a systematic literature review and meta-analysis

Julie Myers  1 , Ronald C Wielage, Baoguang Han, Karen Price, James Gahn, Marie-Ange Paget, Michael Happich
Affiliations
Meta-Analysis

The efficacy of duloxetine, non-steroidal anti-inflammatory drugs, and opioids in osteoarthritis: a systematic literature review and meta-analysis

Julie Myers et al. BMC Musculoskelet Disord. .

Abstract

Background: This meta-analysis assessed the efficacy of duloxetine versus other oral treatments used after failure of acetaminophen for management of patients with osteoarthritis.

Methods: A systematic literature review of English language articles was performed in PUBMED, EMBASE, MedLine In-Process, Cochrane Library, and ClinicalTrials.gov between January 1985 and March 2013. Randomized controlled trials of duloxetine and all oral non-steroidal anti-inflammatory drugs and opioids were included if treatment was ≥12 weeks and the Western Ontario and McMaster Universities Index (WOMAC) total score was available. Studies were assessed for quality using the assessment tool from the National Institute for Health and Clinical Excellence guidelines for single technology appraisal submissions.WOMAC baseline and change from baseline total scores were extracted and standardized. A frequentist meta-analysis, meta-regression, and indirect comparison were performed using the DerSimonian-Laird and Bucher methods. Bayesian analyses with and without adjustment for study-level covariates were performed using noninformative priors.

Results: Thirty-two publications reported 34 trials (2 publications each reported 2 trials) that met inclusion criteria. The analyses found all treatments except oxycodone (frequentist) and hydromorphone (frequentist and Bayesian) to be more effective than placebo. Indirect comparisons to duloxetine found no significant differences for most of the compounds. Some analyses showed evidence of a difference with duloxetine for etoricoxib (better), tramadol and oxycodone (worse), but without consistent results between analyses. Forest plots revealed positive trends in overall efficacy improvement with baseline scores. Adjusting for baseline, the probability duloxetine is superior to other treatments ranges between 15% to 100%.Limitations of this study include the low number of studies included in the analyses, the inclusion of only English language publications, and possible ecological fallacy associated with patient level characteristics.

Conclusions: This analysis suggests no difference between duloxetine and other post-first line oral treatments for osteoarthritis (OA) in total WOMAC score after approximately 12 weeks of treatment. Significant results for 3 compounds (1 better and 2 worse) were not consistent across performed analyses.

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Figures

Figure 1
Figure 1
Article selection flow chart. *Reporting 34 studies.
Figure 2
Figure 2
Funnel plot of standard error by difference in mean. Note: o = actual publication; ● = hypothetical omitted study.
Figure 3
Figure 3
Network of evidence including direct and indirect comparisons. Note: the numbers represent number of comparisons between treatments.
Figure 4
Figure 4
Forest plot by baseline WOMAC showing difference in change from baseline. Note: the lower limit in the Markenson study extends beyond the -20.00 scale of the plot.
Figure 5
Figure 5
Correlation between baseline WOMAC score and the relative effect of active treatments and placebo.
See this image and copyright information in PMC

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