The first evidence-based recommendations on the management of hand osteoarthritis have been developed by a multidisciplinary group commissioned by the European League Against Rheumatism.
Previous European League Against Rheumatism (EULAR) task forces have issued guidelines on the management of knee and hip osteoarthritis (OA), but many of the clinical consequences of small-joint OA, such as interference with grip and fine precision pinch, differ from those associated with large-joint OA, making distinct recommendations necessary.
Interventions therefore have been developed in a site-specific fashion, with 11 key recommendations regarding various types of treatments having emerged from an examination of research-based evidence and expert consensus. (See box.)
Among general considerations addressed are the principle that treatment must be individualized according to the patient's symptoms, severity of disease, and expectations. The patient also should be educated regarding joint protection and exercise.
Nonpharmacologic measures that can be useful include splints and topical analgesics. Such local treatments are preferred over systemic treatments, particularly in limited, mild disease.
First-line pharmacologic therapy is oral paracetamol (acetaminophen), which can be given in doses up to 4 g/day. Other options include nonsteroidal anti-inflammatory drugs and slow-acting agents such as glucosamine and chondroitin sulfate.
Intra-articular injections of corticosteroids also can be beneficial for painful flares, and surgical procedures such as interposition arthroplasty are recommended for patients who do not respond to more conservative measures (Ann. Rheum. Dis. 2006 Oct. 17 [Epub doi:10.1136/ard.2006.062091]).
The EULAR task force noted that there is “a real paucity of clinical trials to guide recommendations for hand OA,” and that many of their recommendations are based on expert committee reports and/or clinical experience, rather than randomized trials. Aside from their clinical recommendations, therefore, the task force also highlighted the need for well-conducted clinical trials that would provide a more definitive evidence base.
The EULAR Recommendations
The guidelines for the management of hand OA are as follows:
Optimal management of hand OA requires a combination of nonpharmacologic and pharmacologic treatment, individualized to the patient's needs.
Individualize therapy according to site, risk factors, type of OA, presence of inflammation, severity of structural change, and level of pain and disability.
Educate patients on how to protect their joints and give them an exercise regimen involving both range of motion and strengthening exercises.
Application of heat, especially before exercise, and ultrasound are helpful.
Splints for thumb base OA and orthoses to correct lateral angulation and flexion deformity are recommended.
Topical nonsteroidal anti-inflammatory drugs (NSAIDs) and capsaicin are useful, especially for mild to moderate pain involving only a few joints.
Acetaminophen is the oral analgesic of choice in dosages of up to 4 g/day.
For patients who respond inadequately to acetaminophen, oral NSAIDs can be used in the lowest effective dose and for the shortest duration needed. Patients at risk for GI adverse effects should receive a gastroprotective agent or a selective COX-2 inhibitor, but for those at cardiovascular risk, coxibs are contraindicated and nonselective NSAIDs should be used with caution.
Symptomatic slow-acting drugs for osteoarthritis—including glucosamine, chondroitin sulfate, avocado soybean unsaponifiables, diacerhein, and intra-articular hyaluronan—may provide some benefit with low toxicity, but suitable patients have not been defined.
Intra-articular injections of long-acting corticosteroids are effective for symptomatic flares of OA, particularly at the trapeziometacarpal joint.
Surgical procedures such as interposition arthroplasty can be beneficial for severe thumb base OA and may be considered when conservative measures have failed.