Highlights from

ACR 2020

ACR Convergence 2020

Virtual 5 - 9 November 2020

Methotrexate might be beneficial for knee osteoarthritis with signs of inflammation

In a trial that tested methotrexate as treatment for patients with knee osteoarthritis (OA) with signs of inflammation, the results showed a significant improvement in function and laboratory markers of inflammation. Methotrexate may be considered in such patients if conventional treatments fail.

“We see patients with knee OA almost every day who are usually advised non-pharmacological interventions and analgesics only. Only when the pain becomes unbearable they are asked to go for knee replacement,” Prof. Biswadip Ghosh (Institute of Post Graduate Medical Education and Research, India) described the current situation [1]. “Most patients suffering from knee OA have episodes of inflammation and each such episode not only increases the pain, but also further damages the joint,” he further pointed out.

The presented trial assessed the efficacy of methotrexate versus glucosamine as a substitute for placebo in adults with primary radiographic confirmed knee OA with joint swelling and ≥6 months of pain. Based on erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) measurements at baseline, 249 patients were assigned to an inflammatory group (n=172) or a non-inflammatory group (n=77). Among the exclusion criteria were Kellgren and Lawrence grade 4 OA, recent intra-articular injections, and uncontrolled metabolic conditions such as diabetes or gout.

Patients assigned to the inflammatory group of the trial had either increased ESR (>30 mm in the 1st hour) and CRP (>1.5 times the reference value) on 1 occasion, or 1 of these parameters at 2 different times that were 1 month apart. Patients in this group also underwent further diagnostic imaging with musculoskeletal ultrasound, X-ray, and MRI. Patients in the inflammatory group were then randomised to treatment with methotrexate or glucosamine with a follow-up time of 3 months.

Baseline demographics showed a mean age of 51.85 versus 51.56 and a Western Ontario and McMaster Universities Arthritis Index (WOMAC) in the modified Pune version of 45.20 versus 49.36 in the non-inflammatory versus the inflammatory group.

In the patients in the inflammatory group that were treated with methotrexate, ESR significantly decreased compared with baseline (P=0.0007). WOMAC decreased from a mean of 52 at baseline to a mean of 38 after methotrexate (P<0.0001), indicating better physical function. In the patients in the inflammatory group that were treated with glucosamine, changes of ESR and WOMAC were not significant.

“In conclusion, we should look for inflammation in symptomatic primary knee OA patients and, if present, we should treat it with anti-inflammatory agents,” recommended Prof. Gosh. He suggested that methotrexate may be considered in such patients if conventional treatments fail, but also pointed to the need for more research regarding the role of inflammation in knee OA patients.

  1. Gosh B, et al. Comparison of Methotrexate and Glucosamine in Primary Knee Osteoarthritis with Inflammation. P1648, ACR Convergence 2020 Virtual Annual Meeting, 5-9 November 2020.

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