(Clinical Scenario) 60 y/o20309.01035(osteoarthritis) (glucosamine)? *

Patients concern (glucosamine)(osteoarthritis)? (glucosamine)?*

*OsteoarthritisThe most common type of joint diseaseBiochemical breakdown of entire joint organ, including subchondral bone and synovium. Weight-bearing joints : Knees, hips, cervical and lumbosacral spine, feet.The goals of management of patients with osteoarthritis (OA) are to control pain and swelling, minimize disability, improve the quality of life, and educate the patient about his or her role in the management team.

*Therapeutic approach to osteoarthritis

Recommendations *AAOS does not recommendglucosamineand/or chondroitin sulfate or hydrochloride for patients with symptomatic OA of knee.SMOH recommend patients failing to respond to both analgesics and nonpharmacologic interventions that want to try glucosamineshould be givenglucosaminesulfate 1,500 mg QD.

(PICO-I)*

P(Patient/Problem)Patients with knee osteoarthritisI(Intervention)GlucosamineC(Comparison)PlaceboO(Outcomes)Pain managementType

(PICO-II)*

P(Patient/Problem)Patients with knee osteoarthritisI(Intervention)GlucosamineC(Comparison)PlaceboO(Outcomes)Adverse effects (uric acid...etc.)Type

*

**

,*

PPatients with osteoarthritisKey wordsOsteoarthritisIGlucosamineKey wordsGlucosamineCPlaceboKey wordsnilOPain managementKey words

* Syntheses

Question typeStudy designDiagnostic testProspective, blinded cross-sectional study comparing with gold standardPrognosisCohort study > Case control study > Caseseries study> > EtiologyCohort study > Case control study > Caseseries study> > TherapySystematic review of randomized control trials> Randomised control trial (RCT)PreventionRandomised control trial (RCT) Cost effectivenessEconomic analysis

Osteoarthritis, Glucosamine *

*Osteoarthritis, Glucosamine

*Osteoarthritis, Glucosamine

*Osteoarthritis, Glucosamine

*Osteoarthritis, Glucosamine

*

PICO11242223121

* Level of evidence: 1Systemic review of RCTs(Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence)

*

PICOPPatients with osteoarthritis YesIGlucosamine YesCPlacebo/NSAID YesOPain relief/Functional preservation/Toxicity Yes

*Critical Appraisal Skills Program (CASP) Validity Importance Practice

?? ??meta-analysis??

*CASP- Systematic review YesTo assess the effectiveness and toxicity of glucosamine in the pharmacological management of OA. Both symptomatic effectiveness and structural effectiveness (that is, delay in radiological progression of OA) were evaluated.

?

*CASP- Systematic review YesValidityThe first criteria were used to screen all citations that involved glucosamine in the management of OA. The second criteria were used to identify those studies that met the following additional requirements: 1) RCTs evaluating the efficacy and toxicity of glucosamine in OA, 2) both placebo-based and comparative studies were eligible, 3) both single-blinded and double-blinded trials were eligible, 4) studies to be included in the quantitative portion of the review (meta-analysis) must have presented suitable quantitative data for pooling across trials, 5) studies that enrolled participants with OA at any body site were eligible with the only exception being studies that evaluated glucosamine in temporomandibular joint (TMJ) disorders, 6) only studies which evaluated glucosamine-only preparations were included (studies which evaluated combination products containing glucosamine in association with other active compounds, for example chondroitin, were excluded), 7) glucosamine could have been administered by any route.

?

*CASP- Systematic review YesValidityA MEDLINE search (1966 to November 1999) was used to identify all relevant RCTs for the first version of this Cochrane Review. For the second version of the Cochrane Review, all searches were updated (in January 2005). The same MEDLINE search strategy was extended for this updated version of the review (up to week 1, January 2008). MEDLINE In-Process and other non-indexed citations were also searched (January 2008); MEDLINE Daily Update was searched (January 2008). In addition, the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library), AmericanCollege of Physicians (ACP) JournalClub, andDatabase of Abstracts of Reviews of Effectiveness (DARE) were searched (up to January 2008); Allied and Complementary Medicine (AMED) was searched (1985 to January 2008); and EMBASE was searched (1980 to week 2, January 2008

?

*CASP- Systematic review YesValidityTwo review authors (TT and TP or LM) used the screening criteria to review all identified citations independently. All citations identified by either investigator were retrieved and analyzed for suitability. Authors of abstracts were contacted requesting the full manuscript, including the raw and final data incorporating the results.

(quality)?

*CASP- Systematic review YesImportance

??

*CASP- Systematic review YesImportance

??

*CASP- Systematic review YesImportance

??

*NNT;number needed to treatPractice? Yes

RRARRRRRNNT1.52[ 1.20, 1.91 ]17.5%26.6%6

*10017Lequesne Index(NNT=6)10 10

AB

*

*

*

Cost of Preventing an Event (COPE) NNT Time Cost (NT.)

DrugFormulationCostDOTCOPEGlucosamine250 mg/cap~1.51500 mg QD 180 days~1620

Back to our patient* Yes Yes Yes Unclear

?Knee OA ? ?NSAID, IA glucocorticoid, IA hyaluronans ?COPE~1620

*1.

***Systemic review of RCTsEvidence

*I2 low: 0.5*I2 low: 0.5*http://www.nhi.gov.tw/I2: I2=(Q-df)/Q x 100% (df=study numbmer -1) low: 0.5Cochran Q(Q-TEST)Q/df>1=>possible heterogeneity.Q/dfno heterogeneity.

http://www.nhi.gov.tw/I2: I2=(Q-df)/Q x 100% (df=study numbmer -1) low: 0.5Cochran Q(Q-TEST)Q/df>1=>possible heterogeneity.Q/dfno heterogeneity.

*http://www.nhi.gov.tw/*