Monday Weekly Update

How do ibuprofen, ketorolac, and diclofenac compare for the treatment of acute, nonradicular low back pain in adults? This study found no differences among ibuprofen, ketorolac, and diclofenac in the primary outcome of overall clinical improvement at 5 days in adults presenting to the emergency department with acute, nonradicular low back pain. Some of the secondary outcomes favored ketorolac, however, leaving open the possibility that ketorolac is superior to ibuprofen and/or diclofenac. As the saying goes, "Absence of proof is not proof of absence." Irizarry E, Restivo A, Salama M, et al. A randomized controlled trial of [...]

Is there an association between gastric cancer and the use of proton pump inhibitors? This is the strongest evidence to date that there is a small but clinically significant increase in the risk of gastric cancer for patients taking a PPI (number needed to treat to harm = 1191 over 10 years). Physicians initiating anti-acid therapy for patients should begin with an H2RA, and if prescribing a PPI, should use the lowest dose and duration possible. Another recent study in the same journal using data from a Korean registry produced similar findings (Gut 2021;70:2066-2075 doi:10.1136/gutjnl-2020-323845). Abrahami D, McDonald EG, [...]

Is leukocyte-rich plasma less effective than leukocyte-poor plasma when injected into the knees of adults with osteoarthritis? In this study limited by the absence of a placebo wing, leukocyte-rich and leukocyte-poor PRP injections were comparably effective in relieving pain in adults with mild to moderate knee osteoarthritis. Since it is unclear whether this treatment is any better than placebo, the American College of Rheumatology strongly recommends against using PRP injections. Di Martino A, Boffa A, Andriolo L, et al. Leukocyte-rich versus leukocyte-poor platelet-rich plasma for the treatment of knee osteoarthritis: a double-blind randomized trial. Am J Sports [...]

Is an intramuscular glucocorticoid injection noninferior to an intra-articular glucocorticoid injection in reducing knee pain in adults with knee osteoarthritis? This study found that IA glucocorticoid injection may work better for reducing pain from knee OA at 1 month, but there was no significant difference in pain resolution between IA injection and IM injection at 2 months or 6 months. Wang Q, Mol MF, Bos PK, et al. Effect of intramuscular vs intra-articular glucocorticoid injection on pain among adults with knee osteoarthritis. The KIS randomized clinical trial. JAMA Network Open 2022;5(4):e224852 [...]

Are postoperative opioids more effective than nonopioids in reducing pain after minor or moderate surgical procedures? In this well-done systematic review, opioids for managing postoperative pain following minor or moderate surgery were no more effective than nonopioids and caused more adverse effects. None of the studies included major or complex procedures, so the jury is still out for those, but the preponderance of recent data suggest that the verdict is unlikely to be much different. In this well-done systematic review, opioids for managing postoperative pain following minor or moderate surgery were no more effective than nonopioids and [...]

Does intensive urate lowering improve outcomes in persons with erosive gout? In adults with erosive gout, intensive urate lowering is difficult to achieve, takes a lot of medications, and does not improve outcomes. Dalbeth N, Doyle AJ, Billington K, et al. Intensive serum urate lowering with oral urate-lowering therapy for erosive gout: a randomized double-blind controlled trial. Arthritis Rheumatol 2022;74(6):1059-1069.

Are platelet-rich plasma injections, either single or multiple, more effective than saline injections in adults with early symptomatic degenerative joint disease of the knee? This is yet another study — this one of higher quality than the others — that finds PRP injections, singly or serially, to be no better than saline injections in improving outcomes in adults with mild radiographically confirmed degenerative joint disease of the knee. Lewis E, Merghani K, Robertson I, et al. The effectiveness of leucocyte-poor platelet-rich plasma injections on symptomatic early osteoarthritis of the knee: the PEAK randomized controlled trial. Bone Joint [...]

What is the best dose of aspirin for secondary prevention in persons with established atherosclerotic cardiovascular disease? There is no advantage to a 325-mg dose of aspirin for patients with established atherosclerotic cardiovascular disease (ASCVD), and people taking the higher dose often switched to the lower dose (although the reason is unclear). Just stick with 81 mg. Jones WS, Mulder H, Wruck LM, et al. Comparative effectiveness of aspirin dosing in cardiovascular disease. N Engl J Med 2021;384(21):1981-1990.

How do ibuprofen, ketorolac, and diclofenac compare for the treatment of acute, nonradicular low back pain in adults? This study found no differences among ibuprofen, ketorolac, and diclofenac in the primary outcome of overall clinical improvement at 5 days in adults presenting to the emergency department with acute, nonradicular low back pain. Some of the secondary outcomes favored ketorolac, however, leaving open the possibility that ketorolac is superior to ibuprofen and/or diclofenac. As the saying goes, "Absence of proof is not proof of absence." Irizarry E, Restivo A, Salama M, et al. A randomized controlled trial of ibuprofen versus ketorolac [...]

Are platelet-rich plasma injections effective for alleviating pain and improving function in adults with symptomatic ankle osteoarthritis? This study found no evidence that supports a benefit of PRP injections compared with saline placebo injections for improving function or reducing pain in adults with symptomatic ankle osteoarthritis. Paget LDA, Reurink G, de Vos RJ, et al, for the PRIMA Study Group. Effect of platelet-rich plasma injections vs placebo on ankle symptoms and function in patients with ankle osteoarthritis. A randomized clinical trial. JAMA 2021;326(16):1595-1605.