Prednisolone an effective short-term option for hand OA

Short-term treatment with 10 mg prednisolone is efficacious and safe for the treatment of patients with painful hand osteoarthritis (OA) and signs of inflammation, research suggests. 

The HOPE study, published in The Lancet, comprised 92 patients with finger joint rather than thumb symptoms – four or more DIP/PIP joints with osteoarthritic nodes, at least one DIP/PIP joint with soft swelling or erythema, and at least one DIP/PIP joint with a positive power Doppler signal or synovial thickening of at least grade 2 on ultrasound.

Participants also had finger pain of at least 30 mm on a 100-mm visual analogue scale (VAS) that flared up during a 48-hour NSAID washout by at least 20 mm on the VAS.

The study randomised participants to either 10 mg oral prednisolone solution or placebo daily with the option of up to 3,000 mg paracetamol as a rescue medication.

After six weeks of treatment, after which treatment was tapered for two weeks then stopped, VAS-reported finger joint pain was -21.5 with prednisolone versus -5.2 with placebo.

The proportion of patients achieving OMERACT-OARSI responder criteria was 72% versus 33% respectively (OR 5.3).

In most secondary outcomes related to pain and function, prednisolone was superior to placebo at six weeks. Rescue medicine use was also lower in treated patients than controls (20% v 38%).

The rates of non-serious adverse events were the same in both groups (41% v 41%) and serious adverse events were few.  One patient in the treatment group discontinued the study after a myocardial infarction and three patients in the control group discontinued due to surgery of the bowel, an infected leg haematoma and Lyme disease arthritis of the knee.

“The results of our study provide clinicians with a new short-term treatment option for patients with hand osteoarthritis who report a flare-up of their disease,” the Dutch study authors concluded.

They noted a previous trial had failed to show benefit with 5 mg prednisolone and while NSAIDs were widely used, their effects were typically modest, associated with known adverse events and contraindicated in some patients such as those on as antihypertensive medications.  

In an accompanying Comment on the study, Professor Graeme Jones and Professor Tania Winzenberg from the Menzies Institute for Medical Research, University of Tasmania said the findings pointed to “a clear and effective short-term option” for the management of hand OA pain.

However the benefits “rapidly tapered off after withdrawal, returning to baseline by the end of the trial.”

They said the few treatments for hand OA included topical capsaicin and diclofenac. Trials of corticosteroid injections has been inconsistent leaving a treatment gap for a disabling condition.

“Kroon and colleagues provide a clear and effective short-term option for those with hand osteoarthritis pain that flares up in response to withdrawal of NSAIDs, especially if they have symptoms and signs of inflammation, such as night pain, morning stiffness, and soft tissue swelling.”

“If these signs and symptoms were present, we would not see the need to image the joints, unless the clinician has easy access to ultrasound in their clinic, meaning that this treatment approach could be used not only by specialist rheumatologists but also in primary care for patients with more severe disease,” they wrote.

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