Methotrexate for pain relief in knee osteoarthritis: an open-label study.

OBJECTIVE: Synovitis is very common in knee OA and associated with pain. This open-label study evaluated an anti-synovitis therapy, MTX, for pain relief in knee OA. METHODS: Inclusion criteria included pain visual analogue scale (VAS) >40/100 mm, ACR clinical criteria for knee OA and intolerance/inefficacy of NSAID and opioids. US at baseline and 24 weeks assessed effusion and synovial thickness. Patients received MTX up to 20 mg/week for 24 weeks. RESULTS: Thirty participants were recruited; mean age 64.5 years, median pain VAS 68 mm. At 24 weeks, 13/30 (43%) achieved ≥30% reduction in pain VAS, 7 (23%) achieved ≥50% reduction and 4 (13%) had worsened. Thirteen achieved Osteoarthritis Research Society International (OARSI) responder criteria. All had effusion/synovitis at baseline. There was no correlation between change in imaging and change in pain scores at 24 weeks. CONCLUSION: This open-label trial suggests analgesic efficacy for MTX in OA knee and suggests that a randomized controlled trial is warranted. Trial Registration. Current controlled trials, http://www.controlled-trials.com/, ISRCTN66676866.

New horizons in osteoarthritis.

Osteoarthritis (OA) is the most common type of arthritis worldwide and rapidly increasing with ageing populations. It is a major source of pain and disability for individuals and economic burden for health economies. Modern imaging, in particular magnetic resonance imaging (MRI), has helped us to understand that OA is a dynamic remodelling process involving all the structures within the joint. Inflammation is common in OA, with a high prevalence of synovitis seen on imaging, and this has been associated with joint pain. MRI detected changes within the subchondral bone are also common and associated with pain and structural progression. Targeting individual pathologies may offer potential new therapeutic options for OA; this is particularly important given the current treatments are often limited by side effects or lack of efficacy. New approaches to understanding the pathology and pain pathways in OA offer hope of novel analgesic options, for example, monoclonal antibodies against nerve growth factor and centrally acting drugs such as duloxetine, tapentadol and bradykinin receptor antagonists have all recently undergone trials in OA. While treatment for OA has until now relied on symptom management, for the first time, recent trials suggest that structure modification may be possible by treating the subchondral bone.

A randomized, double-blind, placebo-controlled trial of low-dose oral prednisolone for treating painful hand osteoarthritis.

OBJECTIVE: Anti-inflammatory therapies are effective analgesics for OA. This study determined whether low-dose oral prednisolone (PNL) was an effective analgesic for hand OA. METHODS: This was a randomized, double-blind, placebo-controlled trial of people with ACR criteria hand OA and baseline hand pain visual analogue scale (VAS) of >40/100 mm. Participants received 5 mg PNL or placebo daily for 4 weeks. Pain VAS, disease activity VAS, Australian/Canadian Hand Osteoarthritis Index and joint counts were performed at baseline, 4 and 12 weeks. Primary outcome was the change in hand pain VAS at 4 weeks. Analysis of covariance was used for analysis, controlling for baseline values. To explore potential mechanism of action of PNL, non-contrast 0.2 Tesla MRI was performed on the most painful hand at baseline and 4 weeks. RESULTS: A total of 70 participants were recruited (57 women, mean age 61 years, mean baseline pain VAS 61.5 mm); 75% had more than one joint with definite MRI synovitis/effusion. At 4 weeks the adjusted mean reduction in pain VAS was 19.9 mm (PNL group) and 16.8 mm (placebo group) (P = 0.54). There were no statistically significant differences in VAS, Australian/Canadian Hand Osteoarthritis Index or joint counts between placebo and PNL groups at 4 or 12 weeks. A total of 20 participants in each group achieved an Outcome Measures in Rheumatology-Osteoarthritis Research Society International response. Baseline synovitis/effusion did not predict response to treatment. CONCLUSION: This is the first randomized controlled trial of low-dose corticosteroid alone for painful hand OA, which demonstrated that short-term low-dose oral PNL is not an effective analgesic treatment for hand OA. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number Register, www.isrctn.org, Trial number 99697616.

Optimising pain control in osteoarthritis.

A recent large survey showed that 81% of people with osteoarthritis (OA) are in constant pain or are limited in their ability to perform everyday tasks. Patients present with joint pain and stiffness and are often unable to carry out their usual activities which impacts significantly on their quality of life. Anxiety and depression are common in patients with OA and will affect their mood and response to pain so identifying and treating associated anxiety and depression is very important. The PHQ9 and GAD7 can be used to screen for depression and anxiety. The OA process affects all structures within a joint, including the synovial lining and the subchondral bone. When sensitive MRI techniques are used synovitis is found to be almost ubiquitous in painful knee OA. When ultrasound is used, synovitis is seen in up to 45% of patients with painful hand OA. Many current treatments for OA are thought to target the synovium e.g. NSAIDs and this may be why they are effective. Changes in the subchondral bone are also common on MRI and associated with pain. Paracetamol and topical NSAIDs should be tried before oral NSAIDs. Topical NSAIDs are effective in the short-term and are not associated with systemic toxicity. Oral NSAIDs should be used at the lowest effective dose for the shortest possible time. All oral NSAIDs and COX-2 drugs should be prescribed with a PPI. There is less trial data on opioids than on NSAIDs but there is evidence for their efficacy. Patients who have moderate to severe pain that is not responding to oral analgesics or anti-inflammatories may benefit from intra-articular corticosteroids. Timing of analgesia is important. Advise patients to use analgesia before they exercise, so adherence to exercise routines is maintained. Consider long-acting preparations so pain relief is at a maximum throughout the most symptomatic period of the day or night.

Imaging the painful osteoarthritic knee joint: what have we learned?

Pain in the peripheral joints is an increasingly common problem, resulting in significant patient disability and health-care expenditure. Osteoarthritis (OA), a syndrome of joint pain with associated structural changes, is the most prevalent joint disease, yet the etiology of pain in OA is not entirely clear. Traditional assessment of the structure-pain relationship in knee OA has relied on conventional radiography, which has several limitations, not least the discrepancy between symptoms and radiographic findings. MRI has the capability to visualize all the structures within the knee joint, and there is a growing body of work using MRI to examine the correlation between structural findings and symptoms. In large cohort studies, synovial hypertrophy, synovial effusions, and abnormalities in the subchondral bone have been associated with knee pain. Advances in our understanding of the etiology of pain in OA will assist in the identification of further targets for treatment of this common and painful disease.

Biological therapies in osteoarthritis.

Given the paucity of effective therapies and the increasing prevalence of osteoarthritis (OA) with ageing and overweight populations, new therapies for this painful, life-impairing condition are desperately needed, for both symptom relief and structural modification. With a growing understanding that OA involves multiple tissue pathologies including inflammation, many more therapeutic targets have been identified. This review will provide a current overview on the role of biologics in OA, including anti-tumour necrosis factor agents, growth factors and interleukin-1 antagonists.

The role of synovitis in osteoarthritis.

Osteoarthritis (OA) is the most common form of arthritis worldwide yet there is still a lack of effective treatments for this condition. Increasingly, attention has turned to the role of the synovium in OA as it is now recognized, in part from the use of modern imaging techniques, that synovitis is both common and associated with pain. This offers a target for treatment, for both symptom and potential structure modification. In this review we discuss the evidence for histological and imaging-detected synovitis and the current role of antisynovial therapies in OA.