Hand OA: low-dose corticosteroids improve symptoms

In the HOPE trial, a low-dose therapy with corticosteroids substantially reduced pain and decreased signs of inflammation in patients with painful hand osteoarthritis (OA) [1].

Hand OA is one of the most common OA phenotypes, and it has a high clinical burden. It leads to joint pain, disability, decreased hand strength, and reduced quality of life. The rationale of the HOPE trial has been that synovial inflammation is often present in people with hand OA and is a main determinant of both pain and disease progression, as previous data has shown. Therefore, corticosteroids might be a benefit due to their potent anti-inflammatory effect.

The HOPE trial enrolled patients with signs of synovial inflammation who met the ACR criteria for painful hand OA. Patients with ≥4 osteoarthritic nodes involving interphalangeal joints, ≥1 interphalangeal joint with soft tissue swelling or erythema, and ≥1 positive power Doppler signal or synovitis of grade 2 or higher were eligible. Moreover, eligible patients had to have finger pain (VAS ≥30 mm) and flaring ≥20mm upon non-steroidal anti-inflammatory drug washout. They were randomised to receive either prednisolone 10 mg daily for 6 weeks or a placebo. This was followed by a 2-week prednisolone tapering scheme, then 6 weeks without study medications. Outcomes were assessed at 2, 4, 6, 8, and 14 weeks.

A total of 92 people were enrolled in the trial and 42 in each arm completed the study. The average age was 63 years and 79% of the participants were women. The primary study endpoint of the HOPE trial, a mean change from baseline to week 6 in finger pain, assessed on VAS, was -21.5 in the prednisolone and -5.2 in the placebo group, with a mean between-group difference of -16.5 (95% CI -26.1 to -6.9; see Figure). At week 6, 33 patients in the prednisolone group and 15 in the placebo group fulfilled the Osteoarthritis Research Society International responder criteria. Prednisolone was superior to placebo in most secondary clinical endpoints. Additionally, ultrasound synovitis significantly improved at week 6 in the prednisolone group and there was no difference in the power Doppler signal. After drug tapering, between-group differences disappeared. The tolerability of the treatment was good.

“Substantial improvements in pain and function, exceeding effects of currently available therapies, were seen in the trial. Therefore, a short course of 10 mg of prednisolone could be considered a new treatment option for people suffering with hand OA, especially those who experience a flare,” said Dr Féline Kroon (Leiden University Medical Center, the Netherlands). As patients included in this study had pain and signs of inflammation and experienced a flare after withdrawal of pain medication, these results only pertain to this group of patients.

Methotrexate slows radiographic progression

A second study presented during the ACR meeting tried to assess the efficacy of methotrexate in hand OA [2]. In addition, radiographic progression was assessed at baseline. A total of 64 patients were treated prospectively with methotrexate or placebo.

The study did not meet its primary endpoint, a reduction of pain at 3 months, compared with placebo. The same was true at the end of the study after a year. Radiographic progression was assessed as a secondary endpoint. Erosive joints progressed significantly more often to a remodelling phase in the methotrexate group than in the placebo group (27% vs 15%; P=0.03). Similarly, joints with joint space loss appeared to be less eroding in the methotrexate group than in the placebo group (8% vs 29%; P=0.2). “Our results show a structural effect of the treatment that seems to slow the erosive structural progression of digital OA with a seemingly more pronounced effect in patients with early lesions. Our study’s results should encourage new studies to be conducted,” concluded leading author Prof. Christian Roux (Cote d’Azur University, Nice, France). These studies build on prior work showing that TNF inhibitors may slow down erosion progression in hand OA in a setting where the primary outcome around symptoms were likewise not met.

Figure. Primary endpoint of the HOPE trial: VAS-assessed finger pain at week 6 in patients taking prednisolone and placebo [1]

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   1. Kroon F, et al. Abstract 1760. ACR 2019. November 8-13, Atlanta (GO/USA).
   2. Roux Ch, et al. Abstract 1759. ACR 2019. November 8-13, Atlanta (GO/USA).

Posted on 4 February 202017 May 2024