1. Intra-articular hyaluronic acid injections were superior to some oral NSAIDs for treatment of knee osteoarthritis pain.
2. Of all interventions studied, only celecoxib was not superior to acetaminophen for treatment of knee osteoarthritis pain.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Knee osteoarthritis (OA) is a highly prevalent disease, especially among elderly populations worldwide. Numerous drug options for OA treatment can be administered either orally or via intra-articular (IA) injection, and the goal of this systematic review was to determine the relative efficacy of all currently available knee OA treatments. From this, IA hyaluronic acid was more effective than all oral NSAIDs except diclofenac and ibuprofen at controlling knee OA pain. Hyaluronic acid also had positive effects on both function and stiffness outcomes. Regarding oral treatments, the study found that only celecoxib was not superior to acetaminophen for treatment of knee OA pain. Importantly, all treatments except acetaminophen produced significant improvement from baseline pain at three months. Interestingly, IA placebo was more effective than oral placebo at treating knee OA pain. This study was limited due to only comparing monotherapies, only examining short-term treatment effects, and only having data for 19 of 36 possible drug comparisons. The authors also could not rule out publication bias or sponsorship bias, since 90% of the trials included were industry-funded. Despite these shortcomings, the findings support similar, previously-conducted analyses for the treatment of knee OA.
In-Depth [systematic review]: This study included 137 qualifying randomized, controlled trials and examined them using a network meta-analysis procedure. In order to qualify, studies needed to compare at least two OA interventions in human patients, and the overall quality of evidence garnered from these trials was moderate. The treatments compared in this study included acetaminophen, diclofenac, ibuprofen, naproxen, celecoxib, IA corticosteroids, IA hyaluronic acid, oral placebo and IA placebo. The main outcomes of interest were changes in baseline pain, function and stiffness scores after three months. IA placebo was significantly better than oral placebo at controlling knee OA pain with an effect size of 0.29 (95%CrI 0.04-0.54). IA hyaluronic acid was more effective than IA placebo (0.34, 95%CrI 0.26-0.42), oral placebo (0.63, 95%CrI 0.39-0.88), acetaminophen (0.45, 95%CrI 0.18-0.72), celecoxib (0.30, 95%CrI 0.04-0.55), and naproxen (0.25, 95%CrI 0.01-0.49) at treating knee OA pain. Interestingly, celecoxib was not superior to acetaminophen for treatment of knee OA (0.15, 95%CrI 0.00-0.30).
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