Effect of Diacerein vs Celecoxib on Symptoms and Structural Changes in Symptomatic Knee Osteoarthritis (DISSCO)

An International, Multicentre, Double-blind, Randomised Study of the Effect of Diacerein vs Celecoxib on Symptoms and Structural Changes in Symptomatic Knee Osteoarthritis Patients as Assessed by Magnetic Resonance Imaging

Osteoarthritis (OA) of the knee is the most frequent cause of knee pain after the age of 50 years. OA is a joint disease characterised by articular cartilage loss associated with structural changes in the cartilage and adjacent structures. The main symptoms are pain and functional disability. The goals of OA therapy are to decrease pain and maintain or improve joint function. There is evidence that diacerein has both a symptomatic and a structural effect on cartilage, and clinical studies suggest that diacerein therapy significantly decreases OA symptoms when compared to placebo. Diacerein has been shown to inhibit interleukine-1 (IL-1β), and down-regulated IL-1β stimulated secretion of metalloproteinases and aggrecanases, and thereby prevent breakdown of cartilage by these enzymes. Diacerein has no effect on the synthesis of prostaglandins, and therefore no effect on the upper intestinal tract. The purpose of this phase III-IV international, multicentre, double-blind, non-inferiority, randomised, controlled study is to determine the efficacy and safety of diacerein vs. celecoxib on symptoms after 6 months of treatment, and on structural changes after 2 years of treatment in knee OA patients as assessed by magnetic resonance imaging (MRI).

Study Overview

• Status: Completed
• Conditions: Osteoarthritis; Osteoarthritis, Knee
• Intervention / Treatment: Drug: Placebo; Drug: Celecoxib; Drug: Diacerein

Detailed Description

The study was a phase III (Canada and Belgium) or IV (Spain, Austria and Czech Republic) international, multicentre, double-blind, randomized, controlled, parallel-groups, symptom-modifying and structure-modifying clinical study of Diacerein (50 mg twice daily) versus Celecoxib (200 mg once daily).

It was planned that 400 patients (males and females) of at least 50 years of age would take part in the study (approximately 150 patients in Canada and 250 patients in European countries). All patients were included after a Screening Visit (washout of previous medication for osteoarthritis) and randomized at the Inclusion Visit (Day 0) in 2 treatment groups of 200 patients as follows:

• Diacerein arm: one 50 mg capsule taken once a day for one month and 50 mg twice daily thereafter (n = 200 patients),
• Celecoxib arm: one 200 mg capsule once daily (n = 200 patients). All patients were assessed at Screening Visit (Visit 1), Inclusion (Visit 2, Day 0), Visit 3 (Day 60), Visit 4 (Day 120) and Visit 5 (Day 182 / early termination) (symptom study).

The duration of the double-blind study for each patient was up to 182 ± 7 days for the symptom study.

During the study, patients were allowed to take acetaminophen 500 mg, to a maximum of 2 g per day, dispensed at each visit by the investigator for rescue therapy.

Pain and other functional symptoms were primary analysed after 6 months (182 days) of treatment (symptom study).

Acetaminophen was dispensed during the study as rescue therapy in case of pain. However, it was asked to discontinue acetaminophen 48 hours before each study procedure/assessment of efficacy.

• Study Type: Interventional
• Enrollment (Actual): 380
• Phase: Phase 3

Contacts and Locations

Study Locations

• Austria
  • Stockerau, Austria
    • State Hospital Stockerau Karl Landsteiner Institute for Clinical Rheumatology
• Belgium
  • Hornu, Belgium
    • Institut Médical Spécialisé - Centre DISCCA
  • Merksem, Belgium
    • Reumatologie Medizorg Merksem
• Canada
  • Québec, Canada, G1V3M7
    • G.R.M.O (Groupe de recherche en rhumatologie et maladies osseuses) Inc.
  • Quebec
    • Montréal, Quebec, Canada, H2L1S6
      • Institut de recherche en rhumatologie de Montréal
    • Montréal, Quebec, Canada, H3T1Y3
      • PPS Medical Inc
    • Montréal, Quebec, Canada, H4J 1C5
      • Hopital du Sacré Coeur de Montréal du CIUSS du Nord-de-l'île-de-Montréal
    • Pointe-Claire, Quebec, Canada, H9R3J1
      • West Island Rheumatology Research Associates
    • Québec City, Quebec, Canada, G1N 4V3
      • Diex Recherche Quebec Inc.
    • Sherbrooke, Quebec, Canada, J1H1Z1
      • Diex Recherche Sherbrooke Inc.
    • Trois-Rivières, Quebec, Canada, G8Z1Y2
      • Centre De Recherche Musculo-Squelettique
• Czechia
  • Brno, Czechia, 638 00
    • Rheumatology St. Anne's University Hospital Brno
  • Prague, Czechia, 128 50
    • Institute of Rheumatology and Clinic of Rheumatology Charles University
  • Prague, Czechia
    • Affidea Praha, s.r.o.
  • Uherske Hradiste, Czechia
    • Medical Plus S.R.O.
• Spain
  • A Coruna, Spain, 15009
    • Rheumatology Hospital Universitario A Coruna
  • Barcelona, Spain, 08022
    • Rheumatology Instituto Poal de Reumatologia
  • Barcelona, Spain, 08907
    • Rheumatology Bellvitge University Hospital
  • Barcelona, Spain
    • Hospital Quiron, Unidad de Medicina interna
  • Barcelona, Spain
    • Rheumatology Hospital del Mar - Parc de Salut Mar
  • Madrid, Spain, 28935
    • Universitario de Mostoles Río Júcar
  • Sabadell, Spain
    • Departament de Reumatologia Hospital Parc Tauli de Sabadell

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 48 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Men and women of at least 50 years of age;
• Patients followed in an ambulatory clinic;
• Patients presenting primary OA of the knee according to American College or Rheumatology (ACR) criteria;
• Patients with OA of radiological stages 2 and 3 according to Kellgren-Lawrence;
• Patients with a minimum joint space width ≥ 2 mm in the medial tibio-femoral compartment on standing knee X-ray (MRI structural study only);
• Patients with knee pain on most days of the month before entering into the study;
• Patients with a VAS pain score (0-100 mm) while walking on a flat surface ≥ 40 mm (Visit 1 (Screening) and Visit 2 (Inclusion Visits));
• Patients with no clinically significant laboratory abnormalities in the judgment of the investigator;
• Female patients who are postmenopausal with confirmed amenorrhea for at least one year before entering this study and those who underwent tubal ligation, oophorectomy or hysterectomy must agree to a hormonal (folliculo-stimulating hormone [FSH]) dosage at Screening visit ;
• Patients agreeing to sign the Informed Consent Form prior to any study-related activities after having been clearly informed of its methods and constraints;
• Patients not taking part in another clinical study;
• Patients agreeing to respect the protocol by attending the visits related to the study.

Exclusion Criteria:

Criteria related to individual characteristics of the patient

• Patients with secondary knee OA;
• Patients with known hypersensitivity to Diacerein or to anthraquinone-containing product, hypersensitivity to Celecoxib, who have demonstrated allergic-type reactions to sulphonamides, experienced asthma, urticaria or allergic-type reactions after taking sulphonamides, aspirin (acetyl salicylic acid [ASA]), lactose, non-steroidal anti-inflammatory drugs [NSAIDs], acetaminophen or paracetamol;
• Patients with a known history of diarrhoea, more particularly if 65 years of age and older;
• Patients with active malignancy of any type or history of a malignancy within the last five years other than basal cell carcinoma;
• Patients with other bone and articular diseases (antecedents and/or current signs) such as; chondrocalcinosis, Paget's disease of the ipsilateral limb to the target knee, rheumatoid arthritis, aseptic osteonecrosis, gout, septic arthritis, ochronosis, acromegaly, haemochromatosis, Wilson's disease, osteochondromatosis, seronegative spondylo-arthropathy, mixed connective tissue disease, collagen vascular disease, psoriasis, inflammatory bowel disease;
• Pain in other parts of the body greater than the knee pain that could interfere with the evaluation of the index joint;
• Patients with fibromyalgia;
• Patients with isolated knee lateral compartment OA defined by joint space loss in the lateral compartment only;
• Patients with Class IV functional capacity using the American Rheumatism Association criteria;
• Patients who have had surgery in any lower limb or arthroscopy, aspiration or lavage in any lower limb joint within 180 days of the Inclusion Visit (Visit 2);
• Patients who have had meniscal surgery on the study knee;
• Patients who have undergone total knee replacement in the contralateral knee within 180 days prior to the Screening Visit (Visit 1);
• Patients with co-morbid conditions or joint deformity that restrict knee function;
• Patients with a history of heart attack or stroke, or who have had serious diseases of the heart such as congestive heart failure (functional classes II-IV of the New York Heart Association [NYHA]);
• Patients who have significant risk factors for heart attack or stroke will be assessed carefully. Risk factors for heart attack and stroke include high blood pressure (treated or untreated), high cholesterol, diabetes and smoking. The global risk assessment will be assessed using the American Heart Association (AHA) assessment of cardiovascular (CV) risk tables. Patients with high risk of CV events, according to the tables, will be excluded;
• Patients with any significant diseases or conditions, including emotional or psychiatric disorders and substance abuse that, in the opinion of the Investigator, are likely to alter appreciation of OA symptoms or the patient's ability to complete the study;
• Patients with a history of any illness that, in the opinion of the Investigator, might confound the results of the study or pose additional risk to the patient;
• Patients with poorly controlled diabetes mellitus defined as Haemoglobin A1c level >8%;
• Patients with poorly controlled hypertension (sustained Systolic Blood Pressure of > 150 mmHg or Diastolic Blood Pressure > 95 mmHg);
• Patients with any active acute or chronic infections requiring antimicrobial therapy, or serious viral (e.g., hepatitis, herpes zoster, HIV positivity) or fungal infections;
• Patients with a history of recurrent upper gastrointestinal (UGI) ulceration or active inflammatory bowel disease (e.g., Crohn's disease or ulcerative colitis), a significant coagulation defect, or any other condition, which in the Investigator's opinion might preclude the chronic use of Celecoxib or Diacerein. Patients may, at the Investigator's discretion, take a proton pump inhibitor (PPI) or antacids daily as required, with a 2 hour period between intake of study medication and intake of PPI or antacid;
• Patients who have been diagnosed as having or have been treated for esophageal, gastric, pyloric channel, or duodenal ulceration within 30 days prior to receiving the first dose of study medication;
• Patients with chronic liver or kidney disease, as defined by aspartate aminotransferase (AST) or alanine aminotransferase (ALT) > 2.0 times the upper limit of normal (ULN) or blood urea nitrogen (BUN) or serum creatinine > 2.0 times ULN, at the Screening Visit (Visit 1);
• Patients who have a history of intolerance to acetaminophen or paracetamol, opioids or opioid combinations such that it is felt that an adequate non-anti-inflammatory rescue analgesic regimen cannot be safely prescribed;
• Patients who have a history of alcohol or substance abuse within the last 3 years;
• Patients receiving any investigational drug within 30 days or 5 half-lives (whichever is greater) prior to the Inclusion Visit (Visit 2);
• Patients who plan surgery during the study;
• Female patients who are breastfeeding;
• Patients with the impossibility of taking part in the total duration of the study and attending the visits;
• Patients unable to give an informed consent;
• Patients who do not respect the acetaminophen or paracetamol washout period of 48 hours or the NSAID washout period of 1 week before the Inclusion Visit (Visit 2).

Treatment-Related Exclusion:

• Patients using corticosteroids (oral, injectable; exception of intraarticular/soft tissue injection at the exclusion of the target knee), indomethacin, therapeutic dose of glucosamine, chondroitin sulphate or Diacerein or Avocado-Soybean Unsaponifiables (ASU) during the 12 weeks preceding inclusion (intraarticular injections of corticosteroids in the contralateral knee is allowed during the study);
• Patients using hyaluronic acid (intra-articular target knee) during the 26 weeks preceding inclusion;
• Patients using natural health products (e.g. capsaicin, boswellia, willow bark), and creams and analgesic gels (e.g. camphor and alcohol based gels) during one week preceding inclusion;
• Patients using natural health products susceptible to increase the risk of bleeding (e.g. garlic, dong quai, etc.) during one week preceding inclusion;
• Patients receiving radioactive synovectomy (target knee) during the 12 weeks preceding inclusion;
• Patients who are taking NSAIDs and do not want to stop during the study;
• If treatment of osteoporosis (bisphosphonates, selective estrogen receptor modulators [SERMS], thyroid-stimulating hormone [TSH]) is necessary, it will have to be continued, unmodified, for the entire duration of the study;
• Patients who have used compounds containing non-approved agents for arthritis or agents claiming to possess disease/structure-modifying properties in the 14 days prior to the Inclusion Visit (Visit 2);
• Patients who have used medications with matrix metalloproteinase (MMP)-inhibitory properties (e.g. tetracycline or structurally related compounds) within 28 days prior to the Inclusion Visit (Visit 2);
• Patients who require acetaminophen or paracetamol at daily doses > 2000 mg (2g) on a regular basis;
• Patients who are taking a laxative, lithium carbonate, phenytoin or anticoagulants (with the exception of ASA up to a maximum daily dose of 325 mg);
• Patients who have received chondrocyte transplants or underwent other type of cartilage repair procedures in the target joint;
• Patients who use oral or topical coxibs;
• Patients who use calcitonin;
• Patients who use immunosuppressive drugs.

Criteria-Related to Magnetic Resonance Imaging (MRI):

• Patients presenting a counter-indication to an MRI examination;
• Patients whose Inclusion Visit cartilage volume cannot be calculated from the MRI due to advanced OA disease;
• Patients whose Inclusion Visit cartilage volume cannot be calculated from the MRI due to the presence of large fat pads or any other technical reason;
• Patients with study knee not entering in the MRI magnet;
• Patients with abnormal Inclusion Visit findings and/or any other condition, which, in the Investigator's judgment, might increase the risk to the patient or decrease the chance of obtaining satisfactory data through MRI to achieve the objectives of the study.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Diacerein; One placebo capsule once daily in the morning (breakfast) and one diacerein 50 mg capsule once daily in the evening (dinner) for the first month, then diacerein capsules twice daily with meals in the morning (breakfast) and the evening (dinner).	Drug: Placebo; Drug: Diacerein; Other Names: Artrodar, Artrodarin, Artrolyt, Fisiodar, Galaxdar, Glizolan, Verboril
Active Comparator: Celecoxib; One celecoxib 200 mg capsule once daily in the morning (breakfast) and one placebo capsule once daily in the evening (dinner).	Drug: Placebo; Drug: Celecoxib; Other Names: Celebrex

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change Form Baseline in WOMAC A Pain Subscale	Change form baseline in Western Ontario and McMaster Universities Arthritis Index (WOMAC) A pain subscale after 182 days of treatment. WOMAC A pain subscale: 0 - 50 cm; 50 = worse	baseline and 182 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change From Baseline in WOMAC OA Scores	Absolute Changes from Baseline in Western Ontario and McMaster Universities Arthritis Index (WOMAC) after 182 days of treatment. WOMAC scale: 0 - 240 cm; 240 = worse - Intention-To-Treat (N=370) Pain subscale: 0-50cm; 50 = worse; Stifness subscale: 0-20cm; 20 = worse; Function subscale: 0-170cm; 170 = worse Absolute changes in WOMAC scores: <0 = improvement; 0 = stable; >0 = worsening	Day 182 or early termination
Absolute Changes From Baseline in Pain Visual Analogue Scale	Absolute Changes from Baseline in Pain Visual Analogue Scale (VAS): 0-10 cm; 10 = worse	Day 182 or early termination
OARSI Responders	Osteoarthritis Research Society International (OARSI) Responders	Day 182 or early termination
Assessment of Joint Swelling, Effusion or Both	Assessment of Joint Swelling, joint Effusion or Both	Day 182 or early termination
Consumption of Acetaminophen	Overall Daily number of tablets taken during the 6 month study	Day 182 or early termination
Change From Baseline in Patient's Global Assessment of Disease Activity	Change from baseline in global assessment of disease activity was assessed using a VAS scale (0-10cm; 10=worse)	Day 182 or early termination
Global Assessment of Response to Therapy	Between group comparison in Patient's and Investigator's Global Assessment of Response to Therapy using a 0-10 cm disease activity VAS scale: 0 cm = very well; 10 cm = very poorly	Day 182 or early termination
Quality of Life SF-36	Absolute Changes from Baseline in Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the Quality of Life questionnaire SF-36. Scale range for each component (PCS and MCS): minimum = 0, maximum = 100, with higher scores indicating better quality of life. Absolute changes in each component (PCS and MCS): >0 = improvement; 0 = stable; <0 = worsening.	Day 182 or early termination

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Cartilage Volume Loss From Baseline in the Medial Compartment Using MRI	Relative cartilage volume loss from baseline in the medial compartment of the knee using MRI	baseline and 728 days
Cartilage Volume Loss From Baseline in the Lateral Compartment Using MRI	Relative cartilage volume loss from baseline in the lateral compartment of the knne using MRI	baseline and 728 days
Change From Baseline in Synovitis (Synovial Membrane Thickness) Using MRI	Absolute Change from baseline in synovitis (synovial membrane thickness) in the global knee using MRI	baseline and 728 days
Change From Baseline in WOMAC A Pain Subscale	Relative mean change from baseline in WOMAC Pain subscore	baseline and 728 days
Change From Baseline in Global Stiffness Using WOMAC Subscale	Relative Change from baseline in global stiffness using WOMAC subscale	baseline and 728 days
Change From Baseline in Visual Analogue Scale Pain (VAS-Huskisson's)	Relative change from baseline in Visual Analogue Scale pain (VAS-Huskisson's)	baseline and 728 days

Collaborators and Investigators

• Sponsor: TRB Chemedica International SA
• Collaborators: ArthroLab Inc.
• Investigators: Principal Investigator: Jean-Pierre Pelletier, MD, FRCPC, ArthroLab Inc.; Principal Investigator: Jean-Pierre Raynauld, MD, FRCPC, Osteoarthritis Research Unit, University of Montreal Hospital Center

Publications and helpful links

General Publications

• Pavelka K, Trc T, Karpas K, Vitek P, Sedlackova M, Vlasakova V, Bohmova J, Rovensky J. The efficacy and safety of diacerein in the treatment of painful osteoarthritis of the knee: a randomized, multicenter, double-blind, placebo-controlled study with primary end points at two months after the end of a three-month treatment period. Arthritis Rheum. 2007 Dec;56(12):4055-64. doi: 10.1002/art.23056.
• Bartels EM, Bliddal H, Schondorff PK, Altman RD, Zhang W, Christensen R. Symptomatic efficacy and safety of diacerein in the treatment of osteoarthritis: a meta-analysis of randomized placebo-controlled trials. Osteoarthritis Cartilage. 2010 Mar;18(3):289-96. doi: 10.1016/j.joca.2009.10.006. Epub 2009 Oct 14.
• Moldovan F, Pelletier JP, Jolicoeur FC, Cloutier JM, Martel-Pelletier J. Diacerhein and rhein reduce the ICE-induced IL-1beta and IL-18 activation in human osteoarthritic cartilage. Osteoarthritis Cartilage. 2000 May;8(3):186-96. doi: 10.1053/joca.1999.0289.
• Pelletier JP, Mineau F, Fernandes JC, Duval N, Martel-Pelletier J. Diacerhein and rhein reduce the interleukin 1beta stimulated inducible nitric oxide synthesis level and activity while stimulating cyclooxygenase-2 synthesis in human osteoarthritic chondrocytes. J Rheumatol. 1998 Dec;25(12):2417-24.
• Martel-Pelletier J, Mineau F, Jolicoeur FC, Cloutier JM, Pelletier JP. In vitro effects of diacerhein and rhein on interleukin 1 and tumor necrosis factor-alpha systems in human osteoarthritic synovium and chondrocytes. J Rheumatol. 1998 Apr;25(4):753-62.
• Franchi-Micheli S, Lavacchi L, Friedmann CA, Zilletti L. The influence of rhein on the biosynthesis of prostaglandin-like substances in-vitro. J Pharm Pharmacol. 1983 Apr;35(4):262-4. doi: 10.1111/j.2042-7158.1983.tb02929.x. No abstract available.
• Petrillo M, Montrone F, Ardizzone S, Caruso I, Porro GB. Endoscopic evaluation of diacetylrhein-induced gastric-mucosal lesions. Curr Ther Res Clin Exp. 1991;49(1):10-15.
• Pelletier JP, Raynauld JP, Dorais M, Bessette L, Dokoupilova E, Morin F, Pavelka K, Paiement P, Martel-Pelletier J; DISSCO Trial Investigator Group. An international, multicentre, double-blind, randomized study (DISSCO): effect of diacerein vs celecoxib on symptoms in knee osteoarthritis. Rheumatology (Oxford). 2020 Dec 1;59(12):3858-3868. doi: 10.1093/rheumatology/keaa072.

Study record dates

Study Major Dates

• Study Start (Actual): May 1, 2016
• Primary Completion (Actual): June 26, 2018
• Study Completion (Actual): June 28, 2018

Study Registration Dates

• First Submitted: February 10, 2016
• First Submitted That Met QC Criteria: February 22, 2016
• First Posted (Estimated): February 23, 2016

Study Record Updates

• Last Update Posted (Estimated): December 1, 2023
• Last Update Submitted That Met QC Criteria: November 29, 2023
• Last Verified: November 1, 2023

More Information

Terms related to this study

• Keywords: Osteoarthritis; Celecoxib; Phase IV; Knee; Phase III; WOMAC; Diacerein; Canada; Osteoarthritis, Knee; Spain; Czech Republic; Phase III-IV; Austria
• Additional Relevant MeSH Terms: Joint Diseases; Musculoskeletal Diseases; Rheumatic Diseases; Arthritis; Osteoarthritis; Osteoarthritis, Knee; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Peripheral Nervous System Agents; Enzyme Inhibitors; Analgesics; Sensory System Agents; Anti-Inflammatory Agents, Non-Steroidal; Analgesics, Non-Narcotic; Anti-Inflammatory Agents; Antirheumatic Agents; Cyclooxygenase Inhibitors; Cyclooxygenase 2 Inhibitors; Celecoxib; Diacerein
• Other Study ID Numbers: DAR-INT-14-01; 2015-002933-23 (EudraCT Number)