Eular Congress News - EULAR 2020 Report

only when compared with diclofenac (HR,1. 5) and COX- 2 inhibitors (HR, 1. 7).

“For hip fractures, tramadol initiation wasassociated with an increased risk of hipfractures, compared with all NSAIDs, butnot with codeine,” she said. The risk of hipfractures was 40%-50% higher with tramadol versus naproxen (HR, 1. 4), diclofenac andCOX- 2 inhibitors (both HR, 1. 5).

“Our results suggest an unfavourable
safety profile of tramadol use,” Ms. Li
said, suggesting that “several guidelines
on tramadol use in clinical practice might
need to be revisited.”
According to a recent Cochrane review
(Cochrane Database Syst Rev. 2019 May
27. doi: 10.1002/ 14651858.CD005522.pub3)
there is “moderate-quality evidence” that
tramadol “has no important benefit on mean
pain or function in people with osteoarthri-
tis.” The authors of the review wrote that,
while some patients might glean a benefit
from treatment, the evidence suggests that
“adverse events probably cause substantially
more participants to stop taking tramadol.”
Current guidance on the use of trama-
dol varies. The American Academy of

Orthopaedic Surgeons guidelines recommend its use in patients with symptomatic knee OA on a par with NSAIDs (J BoneJoint Surg. 2013;95:1885-6) while theAmerican College of Rheumatology guidance (Arthritis Care Res. 2020;72[ 2]:149

62) conditionally recommends that it beused only if there is no real alternative,such as a contraindication to NSAIDs orpain relief is ineffective.

Patients with rheumatic disease areincreasingly taking opioid painkillers suchas tramadol, with other data reported atthe EULAR 2020 E-Congress (Ann RheumDis 2020;79[suppl 1]:174, Abstract OP0280)showing a rise from 15% in 2007 to 25%in 2016 in the Catalonia region of Spainalone. A rise from 5% to 10% has previously been reported in the United Statesfrom 2003 to 2009 (Arthritis Care Res.2014;66[ 10]:1489-95).

With increasing rates of tramadol prescribing, the worry is that perhaps tramadol is not as safe a people think it is, asDr. Thomas Schwenk pointed out when hereviewed the previous research showingexcess mortality with tramadol (NEJMJournal Watch, March 2019).

“The opioid agonist tramadol often is
prescribed for patients with osteoarthritis
pain because it is thought to be safer than
opioids or nonsteroidal anti-inflammatory
drugs,” he observed. Dr. Schwenk, who is
dean of the University of Nevada school of
Medicine, Reno, USA, added that the “re-
sults [of that study] suggest that tramadol
is not as safe as some people believe.”
Responsible prescribing to avoid opioid
misuse in patients with rheumatic dis-
eases was also advocated in a EULAR
press release from the congress. A study
from Iceland (See page 7; Ann Rheum Dis.
2020;79[suppl 1]:58, Abstract OP0088)
was highlighted that found patients with
inflammatory arthritis frequently did not
stop taking opioids after the source of
their pain had gone; in fact, their use went
up despite being treated with tumour ne-
crosis factor inhibitors.

The study authors had no conflicts ofinterest.

Continued from page 11

Use of a self-management smart- phone app may positively impact he health of older patients with self-reported knee and/or hip OA,according to research findings presentedat the congress.

Health Professionals in Rheumatologyabstract award winner Tim Pelle of SintMaartenskliniek, Nijmegen, Netherlands, andcoinvestigators conducted a randomised,controlled trial that found that use of the dr.Bart smartphone app had positive effects onactivities of daily living, pain, and symptomsfor individuals with knee and/or hip OA aged50 years and older.

Despite observing these positive effects, the same benefit was not observedfor the primary outcome of the study, thenumber of knee/hip OA–related secondaryhealth care consultations, compared withusual care in the previous 6 months.

“We were slightly disappointed, be-
cause we hypothesised that dr. Bart app
would result in better self-management
which we assumed to result in change in
healthcare utilisa-
tion patterns; for ex-
ample, optimal use
of primary care ser-
vices and less use
of secondary health-
care services,” Mr.

Pelle said in aninterview.

Self-manage-
ment is of most
importance in the nonsurgical treatment
of patients with knee and/or hip OA, and
modern technologies offer the potential to
support self-management 24/7, he said.
The randomised study included 427 par-
ticipants with self-reported knee and/or
hip OA aged 50 years and older. Study par-
ticipants were randomly assigned to either
the dr. Bart app (n = 214) or usual care (n =
213) for a total of 6 months.

Study subjects completed online questionnaires at the start of the interventionand at 3 and 6 months follow-up. Varioussecondary clinical endpoints were alsoevaluated, including functional limitations,pain, symptoms, self-management behaviour, and others.

The majority of study participants werewomen (72%), with a mean age of 62.1(range, 7. 3) years, and most had symptomsprimarily in their knee(s) (73%).

After analysis, the investigators foundthat app use did not significantly lower thenumber of secondary healthcare consultations, compared with usual care (incidencerate ratio, 1.20; 95% confidence interval,0.67-2.19).