Tools for Practice Outils pour la pratique


#269 Osteoarthritis pain getting you down? Duloxetine  


CLINICAL QUESTION
QUESTION CLINIQUE
Do Serotonin Norepinephrine Reuptake Inhibitors (SNRIs), specifically duloxetine, improve pain in patients with osteoarthritis? 


BOTTOM LINE
RÉSULTAT FINAL
Duloxetine can meaningfully reduce osteoarthritis pain scores (by at least 30%) for ~60% of patients compared to ~40% on placebo. An average pain of ~6 (scale 0-10) will be reduced by ~2.5 points, compared to 1.7 on placebo. Duloxetine adverse effects lead to withdrawal in 12% of patients versus 6% on placebo.  



CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session



EVIDENCE
DONNÉES PROBANTES
Six systematic reviews with 2-7 randomized controlled trials (RCTs) and 487-2102 patients.1-6 Duloxetine 60-120mg daily versus placebo, results statistically significant unless indicated. 
  • Proportion of patients attaining a meaningful pain reduction (generally ≥30% reduction in pain score): 
    • Systematic review (6 RCTs, 2060 patients)1 of hip or knee osteoarthritis, over 10-18 weeks: 64% taking duloxetine versus 43% taking placebo, number needed to treat (NNT)=5. 
    • Other systematic reviews found similar:3,5-6NNT=6-9. 
    • One RCT (231 patients) randomized patients to 60mg or 120mg and found no difference.7 
  • Improvement in baseline pain scores (0-10 point scale, lower scores indicate less pain): 
    • Systematic review (5 RCTs, 2059 patients),5patients started with an average score of 5.8: duloxetine improved pain 0.8 more than placebo, achieving a mean pain score of 3.3 versus 4.1 for placebo which is likely clinically meaningful. 
    • Another systematic review found similar.3 
  • Adverse events: 
    • Overall adverse events:4 55% versus 37% (placebo), number needed to harm (NNH)=6. 
      • Most common adverse events:4 gastrointestinal 36% versus 8% (placebo), (NNH=4). 
        • Specifically6 nausea (NNH 16), fatigue (NNH 17), constipation (NNH 19), erectile dysfunction (NNH 20), abdominal pain (NNH 34). 
    • Withdrawal due to adverse events:4 12% versus 6% (placebo), NNH=17. 
    • Other systematic reviews found similar.1-6 
    • Limitations: all industry-funded studies. 
Context: 
  • No RCTs looked at venlafaxine to treat osteoarthritis pain. 
  • Duloxetine is “conditionally recommended” by the Osteoarthritis Research Society International guidelines and by the American College of Rheumatology, however, tolerability needs to be considered.8-9 
  • A PEER Simplified Decision Aid on osteoarthritis can assist with patient informed decision making and is available online.10 


James Lanz-O'Brien April 24, 2021

These findings are in keeping with those found on the PEER Pain Calculator, which is a tool I use to increase patient buy-in with duloxetine.

Gilbert Bretecher June 5, 2023

Duloxetine fairly effective in reducing OA pain

tia renouf November 14, 2023

nice

Wade Walters January 23, 2024

And may give mood benefit as a bonus.


Latest Tools for Practice
Derniers outils pour la pratique

#374 Vitamin D and Fracture Prevention: Not what it’s cracked up to be?

Does vitamin D prevent fragility fractures?
Read Lire 0.25 credits available Crédits disponibles

#373 Strategies for initiating insulin in type 2 diabetes

What is the optimal initial insulin for patients with type 2 diabetes?
Read Lire 0.25 credits available Crédits disponibles

#372 Mission Slimpossible Part 2: Oral GLP-1 agonists for weight loss

Are oral GLP-1 agonists effective for weight loss?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session


Author(s)
Auteur(s)
  • Betsy Thomas BSc. Pharm
  • Joey Ton PharmD
  • G. Michael Allan MD CCFP

1. Ton J, Perry D, Thomas B, et al. Can Fam Physician. 2020 Mar; 66(3):e89-e98.

2. Moore RA, Cai N, Skljarevski V, Tölle TR. Eur J Pain. 2014 Jan; 18(1):67-75.

3. Wang ZY, Shi SY, Li SJ, et al. Pain Med. 2015 Jul; 16(7):1373-85.

4. Osani MC, Bannuru RR. Korean J Intern Med. 2019 Sep; 34(5):966-973.

5. Gao SH, Huo JB, Pan QM, et al. Medicine (Baltimore). 2019 Nov; 98(44):e17541.

6. Citrome L, Weiss-Citrome A. Postgrad Med. 2012 Jan; 124(1):83-93.

7. Chappell A, Ossanna M, Liu-Seifert H, et al. Pain. 2009 Dec; 146(3):253-60.

8. Bannuru RR, Osani MC, Vaysbrot EE, et al. Osteoarthritis Cartilage. 2019 Nov; 27(11):1578-1589.

9. Kolasinski S, Neogi T, Hochberg MC, et al. Arthritis Rheumatol. 2020 Feb; 72(2):220-233.

10. Lindblad AJ, McCormack J, Korownyk CS, et al. Can Fam Physician. 2020 Mar; 66(3):191-193. Available at: https://www.cfp.ca/content/66/3/191 Accessed 08-APR-2020.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.