General practitioners' advice to use topical rather than oral ibuprofen resulted in equivalent effects on chronic knee pain

ED FROM Underwood M, Ashby D, Carnes D, et al. Topical or oral ibuprofen for chronic knee pain in older people. The TOIB study. Health Technol Assess 2008;12:1–176. Correspondence to: Professor M Underwood, University of Warwick, Coventry, UK; M.Underwood@warwick.ac.uk Sources of funding: Health Technology Assessment Programme; Goldshield Pharmaceuticals supplied starter packs of topical ibuprofen. c Clinical impact ratings: GP/FP/Primary care 6/7; IM/Ambulatory care 6/7; Rheumatology 6/7; Surgery—Orthopaedics 6/7 Advice from general practitioners to use topical v oral ibuprofen for chronic knee pain Baseline scores 12-month scores WOMAC domain* Topical Oral Topical Oral Difference (95% CI){ Pain 39 30 38 36 1 (24 to 6) Stiffness 50 47 46 43 0 (26 to 5) Disability 37 38 39 36 3 (22 to 7) Global assessment 38 39 40 37 2 (22 to 6) *WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index (visual analogue scale, range 0 to 100 [worst]). {Difference in change from baseline, adjusted for baseline values. A positive difference favours oral ibuprofen. CI defined in glossary. C O M M EN TA R Y C ompared with placebo, paracetamol, at doses of 2.6 to 4 g/day, provides a reduction in osteoarthritic pain of modest clinical significance. NSAIDs reduce pain more than paracetamol, especially in severe osteoarthritis, but with increased incidence of gastrointestinal adverse effects. A 2004 systematic review of topical NSAIDs found that they were superior to placebo for osteoarthritis in the first 2 weeks of treatment but not at weeks 3 or 4 (the maximum length of the trials). However, 2 subsequent manufacturer-sponsored trials in patients with knee osteoarthritis showed that topical diclofenac reduced WOMAC pain scores more than placebo at 4 and 12 weeks, respectively. 4 The trial by Underwood et al is the first long-term study comparing an oral with a topical NSAID, ibuprofen. The trial was designed to show equivalence, rather than superiority; the authors concluded that there was no difference in effectiveness. However, the more important finding may be that there was little difference between mean baseline and 12-month WOMAC scores for both preparations (eg, change for global assessment was +2 with topical and -2 with oral ibuprofen). In the absence of a placebo group, it is impossible to conclude whether the 2 treatments were equally mildly effective or equally ineffective. Cristian Baicus, MD Colentina Hospital Bucharest, Romania 1. Towheed TE, Maxwell L, Judd MG, et al. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev 2006;(1):CD004257. 2. Lin J, Zhang W, Jones A, et al. Efficacy of topical non-steroidal anti-inflammatory drugs in the treatment of osteoarthritis: meta-analysis of randomised controlled trials. BMJ 2004;329:324. 3. Bookman AA, Williams KS, Shainhouse JZ. Effect of a topical diclofenac solution for relieving symptoms of primary osteoarthritis of the knee: a randomized controlled trial. CMAJ 2004;171:333–8. 4. Roth SH, Shainhouse JZ. Efficacy and safety of a topical diclofenac solution (pennsaid) in the treatment of primary osteoarthritis of the knee: a randomized, double-blind, vehicle-controlled clinical trial. Arch Intern Med 2004;164:2017–23. Therapeutics 12 EBM February 2009 Vol 14 No 1 on 30 January 2009 ebm.bmj.com Downloaded from

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.