Hand osteoarthritis (OA) is a prevalent and disabling condition, with limited treatment options. Traditionally considered a degenerative condition, the role of low-grade inflammation is becoming increasingly apparent. Now, results from a randomized controlled trial suggest that methotrexate, a broad immunosuppressant already used for the treatment of rheumatoid arthritis (RA), is a safe and cost-effective treatment option for hand OA with synovitis.