METHODS - A randomised controlled trial of METhotrexate to treat Hand Osteoarthritis with Synovitis

Osteoarthritis (OA) is the most common joint disease and frequently involves the hand. Painful hand OA is associated with a significant burden of disease and reduced health-related quality of life. The effect of hand OA on quality of life is comparable to rheumatoid arthritis, but effects considerably more people (prevalence ~40% versus ~1% in older adults). With an ageing population, the burden and health-care costs related to hand OA will increase. Since no treatment affects disease progression, there is an urgent and unmet need for effective treatment to slow structural disease and reduce symptoms. Only treatments that impact on the underlying biological processes causing hand OA will be able to achieve this. Hand OA is a heterogeneous condition. A common phenotype is joint swelling (synovitis). Synovitis is present in approximately 50% of people with symptomatic hand OA. Joints in hands with synovitis are 3.5 times more likely to experience joint destruction and radiographic progression than those without synovitis. Drugs used to treat synovitis may offer a novel therapeutic approach for reducing disease burden from hand OA. Recent efforts to examine anti-synovitis therapies in hand OA have been hampered by their application to the general population, rather than the synovitis phenotype. Moreover, previous attempts to examine anti-synovitis therapies examined costly and poorly accepted drugs. Methotrexate (MTX) is a well-established, low-cost drug with a well-described safety profile commonly prescribed as first-line therapy for the treatment of inflammatory arthritis. Recently, MTX has been shown to improve both synovitis and symptoms in a RCT and open label trial of knee OA. We propose that MTX might be a potential disease modifying OA drug for patients with symptomatic hand OA and synovitis to reduce disease progression and pain.