Osteoarthritis: a new short-term treatment option?

There have been major advances in many areas of rheumatology over the past 20 years, with better and earlier use of traditional disease modifying anti-rheumatic drugs and an increased availability of biological and targeted synthetic disease modifying anti-rheumatic drugs. During this time, the understanding of the pathophysiology of osteoarthritis has markedly increased; however, this increased understanding has not yet translated into improved treatment.

In fact, there are still few available treatments for osteoarthritis, the most prevalent joint disease worldwide. Osteoarthritis trials have often been negative, and the number of options for its treatment have decreased. Most trials have been in knee osteoarthritis, but hand osteoarthritis is equally prevalent and disabling, often affecting several joints in the hand.

To date, there are few therapeutic options with proven effectiveness for hand osteoarthritis.

In brief, these treatment options include topical capsaicin and topical diclofenac. Trials of corticosteroid injections have shown inconsistent results. Although there are several mechanisms acting at the joint level, inflammation is a key pathophysiological factor that is associated with pain and structural change in many observational studies.

Thus, inflammation provides a rational and tempting target for therapy. Several trials

^, 

targeting inflammation have been completed, including trials that only enrolled participants who showed objective evidence of inflammation, but they have not yielded the hoped for benefit. For the treatment of osteoarthritis, low-dose prednisolone (5 mg/day) is ineffective;

hydroxychloroquine is ineffective when all studies were combined;

tumour necrosis factor inhibitors are ineffective,

except some post-hoc analyses that were later tested prospectively and were not confirmed;

and interleukin-1 inhibition is ineffective.

Methotrexate might have small benefits on symptoms or joint structure, based on one knee osteoarthritis trial

from 2007, an as yet unpublished report from an English knee osteoarthritis trial,

and a French osteoarthritis trial,

the initial results of which were reported this year.