Diacerein for Knee Osteoarthritis

Importance: Knee osteoarthritis (OA) is disabling, with few effective treatments. Anti-inflammatory treatments may be effective for patients with an inflammatory phenotype. Objectives: To evaluate the efficacy of the interleukin-1β blocker diacerein, compared with placebo, on knee pain in people with knee OA who have substantial knee pain and inflammation (effusion-synovitis on magnetic resonance imaging). Design, Setting, and Participants: This multicenter, randomized, double-blind, placebo-controlled clinical trial was conducted in 4 Australian centers. Participants with clinical knee OA, substantial knee pain, and effusion-synovitis on magnetic resonance imaging were enrolled from June 2019 to September 2022. Final follow-up occurred on February 6, 2023. Data analysis began on July 7, 2023. Interventions: Participants were randomized (1:1) to diacerein, 50 mg, once daily or identical placebo for the first 2 weeks, which increased to 50 mg, twice daily until 24 weeks if adverse effects were tolerable. Main outcomes and Measures: The primary outcome was change in knee pain as assessed by the visual analogue scale (range, 0-100 mm; minimal clinically important improvement, 15) over 24 weeks. Results: Of 262 participants randomized (mean [SD] age, 54.9 [6.1] years; 147 [56.1%] female and 115 [43.9%] male), 231 (88.2%) completed the trial. Compared with placebo, diacerein did not improve knee pain over 24 weeks (-19.9 mm [diacerein] vs -18.6 mm [placebo]; between-group mean difference, -1.3 mm; 95% CI, -9.8 to 7.3). The most common adverse events were gastrointestinal symptoms, which occurred in 55 participants (41.7%) in the diacerein group and 33 (25.4%) in the placebo group, most commonly diarrhea (51 [38.6%] in the diacerein group vs 29 [22.3%] in the placebo group). Change in urine color was observed among 13 participants (9.8%) who received diacerein. Conclusions and Relevance: This randomized clinical trial found that, in patients with symptomatic knee OA and effusion-synovitis, diacerein (50 mg, twice daily) over 24 weeks resulted in no greater improvement in knee pain compared with placebo. These findings do not support diacerein for treating knee pain in this population. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12618001656224.