First Study to Look at Methotrexate Effect on Hand Osteoarthritis (HOA)
Methotrexate is usually used to treat diseases such as rheumatoid arthritis (RA) and psoriasis; researchers wanted to see if the drug had any applications for treating symptomatic erosive hand osteoarthritis (EHOA) as well. (EHOA means the hand joints are degenerating.) The one-year randomized, double-blind, placebo-controlled study looked at 64 EHOA patients who were randomly sorted into two groups: 10 milligrams of methotrexate per week or placebo. They were checked at 3 and 12 months.
There Aren’t Good Treatments for Erosive Hand Osteoarthritis
“Erosive hand OA poses problems in terms of pain, function, and disability, especially given the lack of truly effective therapies. The natural evolution of erosive hand OA is characterized by a succession of erosive phases and remodeling. These rearrangements suggest the involvement of pro-inflammatory cytokine cascades known to cause cartilage degradation and bone resorption,” said lead author Christian Roux, MD, PhD, professor in the joint unit in the rheumatology department at Cote d’Azur University in Nice, France, in a press announcement. “In recent years, imaging data has confirmed the presence of inflammation in the joints of these patients. The clinical presentation and imaging data bring this entity closer to inflammatory rheumatism, such as rheumatoid arthritis and psoriatic arthritis. These similarities have justified for some the use of treatments used in inflammatory rheumatism.”
Results Are Good News and Bad News
At the end of the year, the researchers found:
Methotrexate seems to reduce the progression of joint damage compared with placebo and significantly facilitate bone remodeling. Bone remodeling is the process by which mature bone is removed and new tissue is formed. Remodeling phases were present in 29 percent of joints in the methotrexate group versus 15 percent of joints in the placebo group, Dr. Roux wrote in an email message.Methotrexate had no appreciable improved effect on pain and function over the placebo.
Results Suggest New Areas of Study; Clues to Future Treatment Timing, Approaches
“The study does not demonstrate superior efficacy of methotrexate over placebo on pain and function in subjects with erosive hand OA. But probably it will be linked to a multifactorial origin of pain in these subjects, such as mechanical or inflammatory pain,” Roux said. “It is possible that we have to treat earlier if we want to have an effect on pain. However, our results show a structural effect of the treatment that facilitates bone remodeling and seems to slow the erosive structural progression of digital osteoarthritis with a seemingly more pronounced effect in patients with early lesions.” Another important point of the study, says Roux, is the good safety of methotrexate. “Our study’s results should encourage new studies to be conducted, and our next step is the conduct of an international study on the use of methotrexate in erosive hand osteoarthritis.”
ACR’s New Guidelines Will Caution Against Methotrexate for Osteoarthritis
At the 2019 American College of Rheumatology annual meeting in November, the organization offers a preview for a new standard of osteoarthritis care, updating its 2012 directive. The ACR draft guidelines recommend against using methotrexate (among other drug agents), stating, “The guideline team found that several agents had been tested since the last update and had failed to show adequate benefit to justify their use, while others will require additional investigations to clarify their place in the osteoarthritis armamentarium. The recommendations against usage of these therapies reflects the fact that pharmacologic options remain limited for the management of OA.” According to the update, a broad research agenda is outlined to address this gap.
How Promising Is the Potential for Methotrexate in OA Treatment?
Guy Eakin, PhD, senior vice president of scientific strategy at the Arthritis Foundation, responds to this recommendation by saying, “Methotrexate has a long history in our communities for other types of arthritis. This study is, formally, contrary to current guidelines but is a good example of the dynamics of research. The new study has just been published, but if replicated, may find itself being a part of future guidelines.”
