Intramuscular methylprednisolone can significantly improve symptoms and function in patients with inflammatory hand pain, a proof of concept study has shown.
To test the hypothesis that predominant hand pain with diurnal variation and morning stiffness lasting for at least 30 minutes has an inflammatory etiology and should respond to corticosteroids, Dr. Zunaid Karim of Chapel Allerton Hospital in Leeds, England, and colleagues evaluated the efficacy of intramuscular methylprednisolone treatment in 102 patients who presented to the Leeds Early Arthritis Clinic with more than 3 months of symptoms and who had failed to respond to nonsteroidal anti-inflammatory drugs (Ann. Rheum. Dis. 2007 Jan. 22 [Epub: doi:10.1136/ard.2006.061861]). Patients with clinical synovitis in five or more joints, as well as those with gout, connective tissue disease, or rheumatoid arthritis were excluded, as were those with sensitivity to corticosteroids or hydroxychloroquine.
The presence of two of the following three conditions was considered indicative of clinical synovitis: joint swelling, joint tenderness, and reduced range of movement. Ultrasound was performed on the second to fifth metacarpal, phalangeal, and proximal interphalangeal joints, and synovitis was defined as the presence of abnormally hypoechoic intra-articular tissue that was nondisplaceable and poorly compressible.
At baseline, 21% of the patients were rheumatoid factor positive, 25% had elevated C-reactive protein levels, and 5% tested positive for antinuclear antibodies, the authors reported. Additionally, 23% of the patients had clinical synovitis and 55% had ultrasound-detected synovitis.
Participating patients received an intramuscular injection of 120 mg of methylprednisolone at baseline and were assessed for response (defined as 50% improvement in pain and stiffness symptoms) at 4 weeks, then every 12 weeks for 48 weeks. Patients who responded initially but subsequently relapsed received an additional methylprednisolone injection and were started on 200 mg daily of hydroxychloroquine, with response assessment after 24 weeks.
Of the initial 102 patients, 11 did not complete the 4-week assessment and were excluded from the study. The remaining 91 patients, mean age 51 years, were predominantly female (81%) and had a mean symptom duration of 7 months.
Response at 4 weeks was observed in 66 of the 91 patients (73%), with associated significant reductions in morning stiffness, Health Assessment Questionnaire results, painful and tender joint counts, and patient visual analog scores, the authors wrote. Both ultrasound-detected synovitis and rheumatoid factor were associated significantly with methylprednisolone response, while clinical synovitis and elevated C-reactive protein were not, the investigators reported.
Of the 66 responders, 24 remained well to the end of the study. The remaining 42 patients relapsed within 24 weeks and received a repeat methylprednisolone injection and hydroxychloroquine. Of these patients, 28 remained on the drug long term and 24 of the 28 reported a benefit, the authors noted. The findings may be limited by the lack of sensitivity of the clinical synovitis assessment. Additionally, it is unclear whether the response seen in the hydroxychloroquine group is a function of the repeat methylprednisolone injection or the hydroxychloroquine.