#VisualAbstract: Methotrexate alleviates pain among patients with hand osteoarthritis and concurrent synovitis

1. Methotrexate 20 mg once weekly resulted in significant pain reduction among patients with hand osteoarthritis of the inflammatory phenotype.

2. Adverse events in the treatment group were comparable to the placebo group.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Hand osteoarthritis is a debilitating condition with limited treatment options. Topical therapy, oral analgesics, and non-pharmacological therapy are used to reduce pain and improve function; however, these have shown limited clinical benefit. Methotrexate may be effective for the treatment of hand osteoarthritis with concomitant synovitis, although limited evidence exists. This randomized controlled trial aimed to assess the safety and efficacy of methotrexate among adult patients with hand osteoarthritis and synovitis. The primary outcome was pain reduction at 6 months measured using a 100 mm visual analogue scale, while the key secondary outcome was a change in functional status. According to study results, methotrexate resulted in significant pain reduction at 6 months, compared to placebo. Although this study was well done, it was limited by a relatively small sample size with no long-term follow-up, thus affecting its validity.

Click to read the study in The Lancet

Relevant Reading: Therapies for Active Rheumatoid Arthritis after Methotrexate Failure

In-depth [randomized-controlled trial]: Between Nov 22, 2017, and Nov 8, 2021, 202 patients were screened for eligibility across multiple community centers in Australia. Included were patients aged 40–75 with hand osteoarthritis (Kellgren and Lawrence grade ≥ 2 in one or more joints) and MRI-detected synovitis ≥ grade 1. Altogether, 97 patients (50 in methotrexate and 47 in placebo) were included in the final analysis. The primary outcome of pain reduction at 6 months, measured using a 100 mm visual analogue scale, was significantly greater in the methotrexate group compared to placebo (-15.2 mm, standard deviation [SD] 24.0 vs. -7.7 mm, SD 25.3; between-group difference -9.9 mm, p=0.037). The majority of adverse events were mild-to-moderate and comparable between groups (62% in methotrexate vs. 60% in placebo). Findings from this study suggest that 20 mg methotrexate for 6 months has a moderate but clinically meaningful effect on reducing pain among patients with hand osteoarthritis and synovitis.

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