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Comparative effectiveness of glucosamine, chondroitin, acetaminophen or celecoxib for the treatment of knee and/or hip osteoarthritis: a network ...
Comparative effectiveness of glucosamine, chondroitin,
            acetaminophen or celecoxib for the treatment of knee
             and/or hip osteoarthritis: a network meta-analysis
      X. Zhu1, D. Wu1, L. Sang1, Y. Wang3, Y. Shen2, X. Zhuang1, M. Chu1, L. Jiang4,1
      1
        Department of Epidemiology, and 2Department of Health Statistics, School of Public Health,
                              Nantong University, Jiangsu Province, P.R. China;
      3
        Affiliated Hospital of Nantong University, Nantong University, Jiangsu Province, P.R. China,
           4
             Collaborative Research Center, Shanghai University of Medicine and Health Sciences,
                                            Shanghai, P.R. China.

                                                          Abstract
                                                           Objective
          To compare the efficacies of oral glucosamine, chondroitin, the combination of glucosamine and chondroitin,
                       acetaminophen and celecoxib on the treatment of knee and/or hip osteoarthritis.

                                                         Methods
  We searched electronic databases including PubMed, Embase, and Cochrane Library and the reference lists of relevant
    articles published from inception to October 23, 2017. A Bayesian hierarchical random effects model was used to
                           examine the overall effect size among mixed multiple interventions.

                                                           Results
     We identified 61 randomised controlled trials of patients with knee and/or hip osteoarthritis. There was no obvious
 difference in the results between the traditional meta-analysis and the network meta-analysis. The network meta-analysis
 demonstrated that celecoxib was most likely the best option (SMD, -0.32 [95% CI, -0.38 to -0.25]) for pain, followed by
  the combination of glucosamine and chondroitin. For physical function, all interventions were significantly superior to
   oral placebo except for acetaminophen. In terms of stiffness, glucosamine (SMD, -0.36 [95% CI, -0.67 to -0.06]) and
      celecoxib (SMD, -0.29 [95% CI, -0.51 to -0.08]) were significantly better compared to placebo. In view of safety,
                 compared to placebo only, celecoxib and acetaminophen presented significant differences.

                                                         Conclusion
      Given the effectiveness of these non-steroidal anti-inflammatory drugs and symptomatic slow-acting drugs, oral
  celecoxib is more effective than placebo on relieving pain and improving physical function, followed by the combination
    of glucosamine and chondroitin. Acetaminophen is likely the least efficacious intervention option. This information,
  accompanied by the tolerability and economic costs of the included treatments, would be conducive to making decisions
                                                        for clinicians.

                                                           Key words
                         osteoarthritis, treatment, glucosamine, chondroitin, acetaminophen, celecoxib

                              Clinical2018
Clinical and Experimental Rheumatology  and   Experimental Rheumatology 2018; 36: 595-602.
Efficacy of oral preparations for the treatment of OA / X. Zhu et al.

Xiaoyue Zhu, MD*                             Introduction                                (12, 13). Furthermore, acetaminophen
Dandong Wu, MD*                              Osteoarthritis (OA), which is charac-       (paracetamol), commonly known as a
Lingli Sang, MD                              terised by progressive cartilage matrix     non-prescription medication for over
Yidan Wang, MD
                                             degradation, subchondral bone sclerosis     50 years, is often recommended as the
Yi Shen, MD
Xun Zhuang, PhD                              and osteophyte formation, is the most       first-line therapy because of its cheap
Minjie Chu, PhD**                            common degenerative joint disease and       price and low risk of gastrointesti-
Liying Jiang, PhD**                          primarily affects weight-bearing joints     nal adverse effects compared to other
*These authors contributed equally to        such as the knee and hip (1, 2). Present-   NASIDs such as aspirin (10). Celecox-
this paper as co-first authors.              ly, OA has emerged as a major public        ib is a selective NSAID that has been
**These authors contributed equally to       health concern and continues to affect      considered the first specific inhibitor
this paper as co-corresponding authors.      approximately 10% of men and 18% of         of cyclo-oxygenase-2 (COX-2) by the
Please address correspondence to:            women over 60 years of age (3), with        American Food and Drug Administra-
Dr Liying Jiang,                             total DALYs increasing by 35% and           tion (FDA) in December 1998(14). Re-
Collaborative Research Center,               age-standardised DALY rates increas-        gardless of its gastrointestinal adverse
Shanghai University of Medicine              ing by 4% between 1990 and 2015. It is      effects, celecoxib has become a typi-
and Health Sciences,                         a leading cause of pain, disability, and    cal inhibitor of COX-2 and reduces its
Shanghai, 200120, P.R. China.
E-mail: J_meili@126.com
                                             socioeconomic costs worldwide (4).          related signs and symptoms (15); it is
                                             Pain symptoms associated with OA            also recommended by OARSI guide-
and
Dr Minjie Chu
                                             may result in increased walking dis-        lines (11). The effects of glucosamine
E-mail: minjie0830@126.com                   ability and all-cause mortality (5).        and chondroitin on knee and/or hip OA
Received on July 25, 2017; accepted in       Therefore, the alleviation and control      compared to a placebo have been stud-
revised form on November 17, 2017.           of pain is an important consideration in    ied by a previous meta-analysis (16).
© Copyright Clinical and                     the clinical practice of OA treatments.     In addition, a meta-analysis on the ef-
Experimental Rheumatology 2018.              Although there are many symptomatic         ficiency and safety of acetaminophen
                                             interventions, most are non-specific        has also been conducted (17). Most
                                             and lack effective disease-modifying        importantly, a clinical trial conducted
                                             medical treatments. Non-steroidal anti-     in 2014 suggested that a certain dosage
                                             inflammatory drugs (NSAIDs) are the         of acetaminophen can provide effec-
                                             most widely used, and symptomatic           tive relief of signs and symptoms (18).
                                             slow-acting drugs (SYSADOAs) for            However, available studies investigat-
                                             OA are accessible in clinical practice.     ing the comparative effects between
                                             Glucosamine and chondroitin are es-         NSAIDs and SYSADOAs are limited.
                                             sential SYSADOAs; they are naturally        At present, the effectiveness of SYSA-
                                             occurring compounds in the body that        DOAs for OA treatment is conflicting
                                             function as the principal substrates in     based on the results of several RCTs
                                             the biosynthesis of proteoglycan (6).       (12, 13, 19). Additionally, compared to
                                             Glucosamine and chondroitin are both        a placebo, the effects of acetaminophen
                                             partially absorbed and then reach the       have been illustrated by a previous
                                             joints, where they relieve joint pain       meta-analysis. Moreover, a comparison
                                             and slow the rate of joint destruction      between acetaminophen and chondroi-
                                             and cartilage loss (7, 8). As a result,     tin, particularly glucosamine and chon-
                                             glucosamine and/or chondroitin are          droitin in combination, has not been
                                             available as over-the-counter products      conducted. Therefore, the comparative
                                             (9). However, recently, the efficacy of     effectiveness of these treatments for
                                             glucosamine, chondroitin, or the com-       OA must be explored.
                                             bination of the two has been widely         A Bayesian network meta-analysis in-
                                             discussed, triggering a fierce contro-      tegrates evidence from all RCTs, which
                                             versy. International guidelines for their   increases the statistical power by com-
Funding: this study was supported by         management have provided an equivo-         bining evidence from direct and indirect
the Research Innovation Program for
College Graduates of Nantong University
                                             cal recommendation of glucosamine           comparisons and examining the rela-
(YKC16019) and the Jiangsu Students’         and chondroitin (10). However, they         tive effects that have few comparisons.
Platform for Innovation and Entrepreneur-    are not recommended according to the        Moreover, it also presents a uniform
ship Training Program (201710304058Z).       Osteoarthritis Research Society Inter-      and reasonable method to identify the
This study did not warrant institutional     national (OARSI) guidelines published       differences among those intervention
review board approval because no human       in 2014 (11). In addition, their effec-     groups (20). Based on the existing evi-
subjects were involved.                      tiveness is conflicting based on several    dence, we have assessed and examined
Competing interests: none declared.          randomised controlled trials (RCTs)         the efficacy and safety of glucosamine,

596                                                                                       Clinical and Experimental Rheumatology 2018
Efficacy of oral preparations for the treatment of OA / X. Zhu et al.

chondroitin, the combination of glu-          eligibility and extracted the data in ac-      those suggested outcomes when more
cosamine and chondroitin, celecoxib or        cordance with a preconfigured form.            than one pain scale was given for a
acetaminophen for primary OA.                 Any disagreements were resolved                trial. Among these scales, global pain
                                              through discussion with a third review-        has precedence over pain on walking
Methods                                       er (L.Y.J.). For each study, the patients’     and the Western Ontario and McMas-
Search strategy                               characteristics including mean age, sex,       ter Universities Osteoarthritis Index
We conducted this network meta-               mean duration of symptoms, BMI, du-            (WOMAC) pain subscale (26, 27).
analysis following the PRISMA exten-          ration of follow-up, type of outcome           Similarly, data on function and stiffness
sion statement (21). We systematically        (pain, function, stiffness and AEs), trial     were extracted with the same method.
searched electronic databases includ-         design, trial size, details of intervention,   If the global function score was not re-
ing PubMed, Embase, and Cochrane              treatment duration and results were in-        ported, the walking disability, function
Library based on logic combinations           dividually extracted. For crossover            subscale of the WOMAC or Lequesne
of keywords and text words associated         trials, we extracted data from the first       Index was applied instead.
with OA to extract concerned RCTs             period only to avoid possible carryover        The standard mean difference (SMD)
from inception to October 23, 2017. The       effects. Data of intention-to-treat analy-     was used to calculate the difference
Internet-based search used the follow-        ses were used whenever possible.               between various intervention arms be-
ing terms: “arthritis”, “osteoarthritis”,                                                    cause different studies assessed the
“OA”, “joint disease”, “glucosamine”,         Quality assessment                             same outcome by employing different
“GH”, “GS”, “chondroitin”, “CH”,              The Cochrane Risk of Bias Tool was             scales. SMD expresses the size of the
“CS”, “acetaminophen”, “paraceta-             used to evaluate the methodological            intervention effect in each study relative
mol”, “celecoxib”, “celebrex”, and the        quality of the included studies (v. 5.3)       to the variability observed in that study
corresponding free terms. The search          (24). The tool evaluates seven potential       by dividing the pooled SD of the dif-
was restricted to the English language        risks of bias: random sequence genera-         ferences between two interventions (28,
and studies of human participants. We         tion, allocation concealment, blinding         29). The effect size was transformed
then screened the reference lists of all      of participants, blinding of outcome           back to the difference units of the
obtained articles, including relevant         assessment, incomplete outcome data,           WOMAC visual analogue scale (VAS),
reviews, to avoid missing relevant ar-        selective reporting and other bias. Each       which is the most commonly used scale
ticles. We also searched Clinical Trials.     item was judged by the following cri-          and is based on a median pooled SD of
gov for progressive trials.                   teria: low risk of bias, uncertain risk        2.5 cm to assess pain on a scale of 0 to
                                              of bias, and high risk of bias. Studies        10 cm. A standardised WOMAC func-
Inclusion and exclusion criteria              that included three or more high risk          tion score (0-10) was transformed by
Studies were included if they met the         of bias areas were considered to have          the SMD, which is based on a median
following criteria: (1) RCTs; (2) stud-       poor methodological quality. The qual-         pooled SD of 2.1 units. A change of 2
ies about primary hip and/or knee OA          ity of evidence on pain, function and          points on the 0–10 scale was interpreted
patients with clinical and/or radiologic      stiffness was evaluated by the Grading         as a clinically significant improvement
diagnosis; (3) studies covering at least      of Recommendations, Assessment, De-            (30). A negative effect size indicated
two of the following treatments: glu-         velopment, and Evaluation (GRADE)              a better treatment effect on pain relief
cosamine, chondroitin, the two in com-        system (25). The quality of evidence           and function improvement. The abso-
bination, acetaminophen, celecoxib,           was presented as high, moderate, low or        lute changes in pain, function and stiff-
and placebo; and (4) extractable data         very low. Two reviewers independently          ness from baseline were also evaluated
reporting on the pain, function, stiffness    evaluated each study.                          by a classical meta-analysis.
and adverse events (AEs) of patients.
The exclusion criteria were as follows:       Outcome measures                               Statistical analysis
(1) studies of non-randomised or uncon-       The primary outcomes of this network           Bayesian meta-analysis integrates both
trolled trials; (2) treatments described      meta-analysis were pain intensity, func-       direct evidence from head-to-head
unclearly; (3) studies or data reported       tion improvement and stiffness score           studies and indirect evidence from all
repeatedly; and (4) trial arms with sub-      from baseline to the end of treatment          original trials. The Bayesian Markov
therapeutic doses (celecoxib not equal        using certain dosages of celecoxib,            Chain Monte Carlo is a method used
to 200 mg/day; acetaminophen below            acetaminophen, glucosamine, chon-              to estimate posterior densities for un-
3000 mg/day;
Efficacy of oral preparations for the treatment of OA / X. Zhu et al.

servative and appropriate than the fixed      Fig. 1. Network of
effects model, was used to examine the        treatment comparisons
                                              included in the analy-
overall effect size among mixed multi-        sis for pain.
ple treatments of OA with non-inform-         The size of every cir-
ative prior distributions. Before pooling     cle reflects the number
                                              of participants.
the data with a random-effects model          The width of every
within a Bayesian framework, the com-         line corresponds to the
parative effects were initially analysed      number of direct com-
                                              parisons; the number
by the traditional pairwise meta-analy-       shown beside the line
sis method. For continuous outcomes,          represents the number
the summary effect size was calculated        of trials.
                                              No connecting line
as the SMD along with 95% credible
                                              between 2 treatments
intervals (CIs). For the count data, the      indicates no direct
relative risk (RR) with 95% CI was used       comparison.
to present the effect size. It was possible
to rank the superior orders among the
included interventions according to the
posterior probabilities, and we reported      The baseline characteristics of the in-      cosamine and chondroitin and acetami-
the value as the surface under the cu-        cluded studies are shown in Supple-          nophen.
mulative ranking (SUCRA). The best            mentary file 1: Table S1 (the references     Fifty-six studies (22,128 participants)
treatment effect has a SUCRA value of         of the included studies are provided).       contributed to the network meta-anal-
100%, whereas the worst treatment ef-         Forty-seven trials covered participants      ysis of pain-related outcomes. Table I
fect has a SUCRA value of 0%. Several         with only knee OA, two trials con-           presents the effect sizes and the related
sensitivity analyses on the primary out-      tained participants with only hip OA,        95% CIs of the network meta-analysis
comes were performed to explore the           and twelve trials included patients with     about the changes in pain score between
heterogeneity according to the sample         knee and/or hip OA.                          different interventions at the last follow-
size and the study quality. We also cal-                                                   up period. All treatments showed a sig-
culated the consistency of the network        Risk of bias                                 nificantly better effect compared to pla-
determined by the difference in effect        The risk of bias of the included trials      cebo. When the SMD was transformed,
sizes from direct and indirect compari-       is summarised in Supplementary file 1:       glucosamine had a value of -0.33 cm
sons in one loop. Publication bias was        Table S2. None of the studies had poor       (95% CI, -0.60 to -0.10 cm), chon-
examined through visual inspection of         methodological quality. Randomisa-           droitin was -0.53 cm (95% CI, -0.83
funnel plot asymmetry. WinBUGS (v.            tion was mentioned in all trials, and        to -0.28 cm), the combination of glu-
1.4.3, MRC Unit, Cambridge, UK),              all studies were judged to have a low        cosamine and chondroitin was -0.58 cm
STATA (v. 13.1, StataCorp, College Sta-       risk of bias for blinding to patients.       (95% CI, -0.98 to -0.18 cm), celecoxib
tion, TX), and Review Manage (v. 5.3,         The quality of evidence was measured         was -0.80 cm (95% CI, -0.95 to -0.63
Oxford, UK) were used for the analyses.       by the GRADE system (Table I). The           cm), and acetaminophen was -0.35 cm
                                              quality grade was downgraded primar-         (95% CI, -0.65 to -0.05 cm). All inter-
Results                                       ily due to indirectness and imprecision      ventions met the pre-specified minimal
Study selection and characteristics           (see details in Supplementary file 1:        clinically significant improvement.
The summary of the study search and           Tables S3-S5). The model fit well for        Celecoxib was statistically significantly
selection is presented in the Appendix        pain, function and stiffness outcomes        superior to acetaminophen (SMD, -0.18
Supplementary file 2: Fig. S1. Among          (Supplementary file 2: Fig. S11). Com-       [95% CI, -0.31 to -0.05]). Compared to
the 3359 records identified and se-           parison-adjusted funnel plots showed         celecoxib, glucosamine showed a worse
lected from the literature search, 3060       no evidence of asymmetry (Supple-            effect (SMD, 0.18 [95% CI, 0.07 to
irrelevant articles were excluded. Af-        mentary file 2: Fig. S5–S7).                 0.29]). According to the SUCRA related
ter screening and reading the full text                                                    to pain, the top three ranked treatments
of 299 articles, 58 articles (61 RCTs)        Pain                                         were celecoxib (96%), the combination
met the inclusion criteria and were in-       Figure 1 shows the network of the inter-     of glucosamine and chondroitin (67%)
cluded in the network meta-analysis, 3        ventions included in this study for pain.    and chondroitin (64%) (Fig. 2). No in-
of which reported the results of two tri-     Six nodes indicated different interven-      consistencies were detected between the
als. Therefore, 61 RCTs were employed         tions of drugs with a specific daily dose.   direct and indirect evidence (Supple-
to assess the efficacies of oral glucosa-     Celecoxib (200 mg/day) was the most          mentary file 2: Fig. S8).
mine, chondroitin, the combination            commonly studied drug. However,
of the glucosamine and chondroitin,           there were few direct comparisons be-        Function
celecoxib and acetaminophen for pa-           tween chondroitin and acetaminophen          Forty-five articles (47 RCTs) with
tients with knee and/or hip OA.               or between the combination of glu-           19,727 patients contributed to the net-

598                                                                                         Clinical and Experimental Rheumatology 2018
Efficacy of oral preparations for the treatment of OA / X. Zhu et al.

Table I. Estimates of the treatment effect on pain, function and stiffness.

Interventions                          Pain, SMD (95% CI)                                 Function, SMD (95% CI                              Stiffness, SMD (95% CI)

                               Network              Direct   GRADE                Network               Direct   GRADE Network                            Direct       GRADE
                             meta-analysis        comparison		                  meta-analysis         comparison		 meta-analysis                        comparison

Glucosamine
Chondroitin             0.08(-0.06,0.22) 0.03(-0.10,0.16)     High     0.04(-0.09,0.18) 0.05(-0.08,0.17)    High    -0.32(-0.85,0.20) -0.07(-0.22.0.09)  High
Glucosamine+Chondroitin 0.09(-0.09,0.27) 0.10(-0.05,0.24)     High     0.05(-0.12,0.22) 0.12(-0.01,0.24)    High    -0.14(-0.69,0.39) 0.09(-0.07,0.24) Moderate
Celecoxib                 0.18(0.07,0.29) -0.04(-0.44,0.37) Moderate    0.14(0.02,0.25) -0.06(-0.56,0,44) Moderate -0.06(-0.44,0.29) 0.13(-0.02,0.29) Moderate
Acetaminophen            0.01(-0.15,0.15) -0.09(-0.36,0.17)   Low     -0.04(-0.21,0.12) -0.05(-0.32,0.22) Moderate -0.28(-0.84,0.26)         NA         Moderate
Placebo                -0.13(-0.24,-0.04) -0.10(-0.25,0.05)   High -0.17(-0.28,-0.07) -0.12(-0.26,0.01)     High -0.36(-0.67,-0.06) -0.30(-0.60,-0.00)   High

Chondroitin
Glucosamine+Chondroitin 0.02(-0.17,0.19) 0.05(-0.17,0.27)     High     0.01(-0.17,0.18) 0.08(-0.05,0.20)    High     0.18(-0.44,0.79) 0.15(-0.00,0.31)   High
Celecoxib                0.10(-0.03,0.23) 0.15(-0.00,0.31)    High     0.09(-0.03,0.21)   0.16(0.00,0.31)   High     0.26(-0.23,0.74) 0.20(0.05,0.36)    High
Acetaminophen           -0.07(-0.24,0.09)         NA         Moderate -0.08(-0.26,0.09)         NA         Moderate 0.04(-0.61,0.68)         NA         Moderate
Placebo                -0.21(-0.33,-0.11) -0.21(-0.36,-0.07)  High -0.22(-0.33,-0.11) -0.22(-0.36,-0.08)    High    -0.04(-0.50,0.42) 0.03(-0.09,0.15) Moderate

Glucosamine+Chondroitin
Celecoxib                0.09(-0.07,0.25) 0.00(-0.11,0.12)    High     0.08(-0.07,0.24) 0.04(-0.12,0.19)    High     0.08(-0.40,0.56) 0.06(-0.06,0.17)   High
Acetaminophen           -0.09(-0.29,0.11)         NA         Moderate -0.09(-0.30,0.11) -0.24(-0.52,0.04)   High    -0.14(-0.79,0.51)        NA         Moderate
Placebo                -0.23(-0.39,-0.07) -0.10(-0.22,0.33)   High -0.23(-0.38,-0.08) -0.12(-0.24,0.01)     High    -0.21(-0.69,0.26) -0.07(-0.21,0.07)  High

Celecoxib
Acetaminophen          -0.18(-0.31,-0.05) -0.18(-0.31,-0.05)  High -0.18(-0.33,-0.03)           NA          Low     -0.22(-0.70,0.26) -0.25(-0.54,0.03) Moderate
Placebo                -0.32(-0.38,-0.25) -0.32(-0.37,-0.27)  High -0.31(-0.38,-0.25) -0.32(-0.37,-0.27)    High -0.29(-0.51,-0.08) -0.28(-0.36,-0.21)   High

Acetaminophen
Placebo                -0.14(-0.26,-0.02) -0.14(-0.21,-0.06)  High    -0.14(-0.27,0.01) -0.16(-0.31, 0.00)  High    -0.08(-0.53,0.38) -0.17(-0.34,0.01)  High

CI: Confidence interval; NA: Not applicable; GRADE: Grading of Recommendations, Assessment, Development, and Evaluation.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

work meta-analysis of physical func-                         network meta-analysis of stiffness out-                       1.12 to 2.95]), whereas acetaminophen
tion outcomes (Supplementary file 2:                         comes (Supplementary file 2: Fig. S3).                        showed a similar value (RR, 1.97 [95%
Fig. S2). All interventions except for                       Compared to placebo, glucosamine                              CI, 1.11 to 3.52]). The safety and tolera-
acetaminophen were statistically sig-                        (SMD, -0.36 [95% CI, -0.67 to -0.59])                         bility analyses are presented in Table II.
nificantly better than oral placebo in                       and celecoxib (SMD, -0.29 [95% CI,
the aspect of function improvement                           -0.51 to -0.08]) were significantly su-                       Sensitivity analysis
(Table I). After being transformed, the                      perior. Other comparisons showed                              To confirm the robustness of the result,
difference for glucosamine was -0.36                         no statistical significance in terms of                       we also conducted sensitivity analy-
units (95% CI, -0.59 to -0.15 units),                        stiffness (Table I). The SUCRA rank                           ses for those outcomes. A sensitivity
chondroitin was -0.46 units (95% CI,                         was presented as follows (Fig. 2): glu-                       analysis of the sample size and meth-
-0.69 to -0.23 units), the combination                       cosamine (82%), celecoxib (73%), the                          odological quality of the included stud-
of glucosamine and chondroitin was                           combination of glucosamine and chon-                          ies did not show any major changes in
-0.48 units (95% CI, -0.80 to -0.17                          droitin (58%), acetaminophen (37%),                           pain, function and stiffness outcomes
units), celecoxib was -0.65 units (95%                       chondroitin (31%) and placebo (20%).                          (Supplementary file 1: Table S6).
CI, -0.80 to -0.53 units), and acetami-                      No significant inconsistencies were de-
nophen was -0.29 units (95% CI, -0.57                        tected between the direct and indirect                        Discussion
to -0.02 units). According to the SU-                        evidence (Supplementary file 2: Fig.                          We estimated the effectiveness of dif-
CRA of function (Fig. 2), celecoxib                          S10).                                                         ferent interventions including glu-
was the best treatment (96%), followed                                                                                     cosamine, chondroitin, the combina-
by the combination of glucosamine and                        Safety                                                        tion of glucosamine and chondroitin,
chondroitin (65%), chondroitin (62%)                         Forty-one articles (44 RCTs) reported                         celecoxib and acetaminophen. In our
and glucosamine (44%), with placebo                          the withdrawal of patients due to AEs,                        study, we performed four individual
as the worst treatment (1%). No incon-                       and 38 studies reported the number of                         outcome-oriented network meta-analy-
sistencies were detected between the                         patients with AEs (Supplementary file                         ses. The pooled effect sizes suggested
direct and indirect evidence (Supple-                        2: Fig. S4). Diarrhoea, abdominal pain,                       that all interventions may alleviate pain
mentary file 2: Fig. S9).                                    nausea and headache were the most                             symptoms and improve function. The
                                                             commonly reported AEs. Compared to                            recommended dosage of oral celecoxib
Stiffness                                                    glucosamine, the celecoxib treatment                          is more effective than placebo on re-
Twenty-nine articles (30 RCTs) with                          option exhibited a relatively higher                          lieving pain and improving physical
12,404 participants contributed to the                       incidence of AEs (RR, 1.82 [95% CI,                           function, followed by the combina-

Clinical and Experimental Rheumatology 2018                                                                                                                               599
Efficacy of oral preparations for the treatment of OA / X. Zhu et al.

                                                                                                     similar findings of the latest RCT (19).
                                                                                                     A recent meta-analysis indicated that
                                                                                                     celecoxib would lead to significant im-
                                                                                                     provements in pain compared to place-
                                                                                                     bo (35). Cao and colleagues combined
                                                                                                     24 RCTs and indicated that oral 200mg
                                                                                                     daily celecoxib was effective for pain
                                                                                                     relief (36). The finding was similar to
                                                                                                     our analysis. Machado and colleagues
                                                                                                     conducted a pair-wise meta-analysis
                                                                                                     and reported that acetaminophen had
                                                                                                     a significant but small effect on hip
                                                                                                     and/or knee OA patients compared to
                                                                                                     placebo within 12 weeks(17). We also
                                                                                                     found that acetaminophen was the least
                                                                                                     efficacious drug when comprehensively
                                                                                                     evaluated. Another network meta-anal-
                                                                                                     ysis indicated that celecoxib was signif-
Fig. 2. The rank of efficacy of pain, function and stiffness.                                        icantly superior to placebo but inferior
Data were pooled as the RR (relative risk) and its related 95% CI; G+C=glucosamine+ chondroitin.     to acetaminophen, which was contrary
                                                                                                     to our findings (30). In our study, dos-
Table II. Adverse event results.                                                                     age was restricted and the RCTs includ-
Comparison                                                             RR (95%CI)                    ed met these criteria, and such results
                                                                                                     could be comparable and reasonable.
Chondroitin vs. Glucosamine                                          1.67 (0.93,3.01)                All of the treatments in our analysis were
G+C vs. Glucosamine                                                  1.70 (0.86,3.37)
                                                                                                     based on the recommendations from
Celecoxib vs. Glucosamine                                            1.82 (1.12,2.95)
Acetaminophen vs. Glucosamine                                        1.97 (1.11,3.52)                the latest clinical practice guidelines.
Placebo vs. Glucosamine                                              1.05 (0.66,1.66)                We compared typical SYSADOAs and
G+C vs. Chondroitin                                                  1.02 (0.53,1.96)                NSAIDs in the treatment of OA. Chon-
Celecoxib vs. Chondroitin                                            1.09 (0.69,1.72)                droitin and glucosamine are believed
Acetaminophen vs. Chondroitin                                        1.18 (0.67,2.08)
                                                                                                     to play a significant role in relieving
Placebo vs. Chondroitin                                              0.63 (0.41,0.96)
Celecoxib vs. G+C                                                    1.07 (0.61,1.88)                joint pain and slowing the rate of carti-
Acetaminophen vs. G+C                                                1.16 (0.59,2.29)                lage loss. As shown in previous studies,
Placebo vs. G+C                                                      0.62 (0.35,1.09)                glucosamine inhibited prostaglandin
Acetaminophen vs. Celecoxib                                          1.08 (0.72,1.63)                release, and chondroitin stimulated col-
Placebo vs. Celecoxib                                                0.58 (0.47,0.71)
                                                                                                     lagen synthesis (37-39). However, the
Placebo vs. Acetaminophen                                            0.53 (0.36,0.78)
                                                                                                     standard intervention focused on symp-
Data were pooled to obtain the relative risk and its related 95% CI; G+C: glucosamine+chondroitin.   tom relief with analgesics and NSAIDs.
                                                                                                     Presently, acetaminophen is the most
tion of glucosamine and chondroitin.                  pain and function from baseline infor-         commonly prescribed over-the-counter
Acetaminophen is likely the least ef-                 mation. Conversely, a traditional meta-        drug, and celecoxib was first specific
ficacious option. In terms of stiffness               analysis suggested that glucosamine            inhibitor of cyclo-oxygenase-2 (40).
improvement, glucosamine showed a                     and chondroitin can present a certain          Indeed, previous meta-analyses have
superior effect compared with placebo,                efficacy in treating OA symptoms (33,          compared the use of SYSADOAs for
whereas acetaminophen did not signifi-                34). However, the findings of a Bayes-         OA disease (16, 33). Several network
cantly differ from placebo. There was                 ian network meta-analysis indicated            meta-analyses were estimated for knee
no significant difference of safety in                that glucosamine, chondroitin and the          OA but were only concerned about dif-
the comparisons between SYSADOAs                      combination of the two did not result in       ferent NSAID treatments (16, 30, 41,
and placebo. Compared with placebo                    a relevant reduction of joint pain com-        42). Given the above reasons, we se-
and glucosamine, celecoxib and aceta-                 pared to placebo (16). The evidence            lected and then conducted a more com-
minophen was a risk factor of AEs,                    of previous study was limited and the          prehensive mixed comparison of those
whereas celecoxib and acetaminophen                   result may not be reliable, because            treatments on knee and/or hip OA.
were recommended in clinical practice.                only one RCT of combined group was             SYSADOAs provide lasting pain relief
Our network meta-analysis indicated                   included. Nevertheless, in our study,          and function improvement in OA treat-
that glucosamine and the combination                  four RCTs covering the combination             ment (43, 44) and beneficial effects that
of glucosamine and chondroitin showed                 of glucosamine and chondroitin were            develop slowly over time(45). Chon-
a greater significant improvement in                  measured, which could support the              droitin and glucosamine were tested in

600                                                                                                   Clinical and Experimental Rheumatology 2018
Efficacy of oral preparations for the treatment of OA / X. Zhu et al.

several clinical trials in osteoarthritis.    results were validated by the model fit      such as the combination of SYSADOAs
In spite of the controversy surrounding       and absence of inconsistency. Funnel         and NSAIDs were usual in clinical ex-
the SYSADOAs, they were commonly              plots also showed no asymmetry, and          perience; furthermore, our study will
used to control symptoms of OA in             the risk of publication bias was not rec-    help highlight the potential role of the
western countries. So, an understanding       ognised. What is more, GRADE was             glucosamine and chondroitin combina-
of chondroitin and glucosamine con-           used to evaluate the quality of the evi-     tion in the future. Therefore, the above
sumption is of significance for public        dence, which provide a more compre-          information, along with the safety pro-
health. The evidence in our study pre-        hensive evidence-based review.               file and relative costs of included treat-
sented that SYSADOAs have a compa-            Some limitations must be acknowl-            ment, should be conducive to clinicians
rable efficacy in both outcome of pain        edged. Firstly, variation length of fol-     when making care decisions tailored to
and function improvement, especially          low-up time point might contribute to        individual patient needs.
for the combination of glucosamine            the evidence of significant heterogene-
and chondroitin. Furthermore, glucosa-        ity. Fortunately, no obvious evidence        References
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