Updated Recommendations for the Management of Hand Osteoarthritis Released by EULAR

The European League Against Rheumatism (EULAR) has issued updated guidelines for the management of hand osteoarthritis (OA), which were published in Annals of the Rheumatic Diseases.

The previous EULAR recommendations for the management of hand OA were released in 2007. Since then, new evidence has emerged, and the task force sought to update recommendations based on the new evidence.

The task forced use the 2014 EULAR Standard Operating Procedure to develop the new guidelines. They performed a systematic literature review of all evidence regarding non-pharmacologic, pharmacologic, and surgical treatment options for hand OA.

An international task force of 19 clinicians, healthcare professionals, and patients from 10 European countries used their expertise in conjunction with the evidence to come up with 5 overarching principles and 10 recommendations.

The 5 overarching principles of managing hand OA are as follows:

• The primary goal is to control symptoms and optimize hand function so that patients can maximize activity, participation, and quality of life.
• Clinicians should offer patients information regarding the nature and course of hand OA as well as education on self-management principles and treatment options.
• Clinicians should individualize the management of hand OA after taking localization, severity, and comorbidities into account.
• Clinicians should base the management of hand OA on a shared decision by the patient and clinician.
• The optimal management of hand OA usually requires a multidisciplinary approach; clinicians should consider non-pharmacologic, pharmacologic, and surgical treatment options.

The 10 recommendations are:

• Clinicians should offer education and training in ergonomic principles, pacing of activity, and the use of assistive devices.
• Clinicians should consider exercises to improve function, improve muscle strength, and reduce pain.
• Clinicians should consider orthoses for symptom relief in patients with thumb base OA. Long-term orthoses use is recommended.
• Topical treatments should be used over systemic treatments due to safety reasons. The first choice of pharmacologic topical treatment is topical nonsteroidal anti-inflammatory drugs (NSAIDs).
• Clinicians should consider a limited duration of oral analgesics, especially NSAIDs, for relief of symptoms.
• Clinicians should consider chondroitin sulfate for pain relief and improvement in functioning in patients with hand OA.
• Generally, intra-articular injections of glucocorticoids should not be used in patients with hand OA. However, they may be considered in patients with painful interphalangeal joints.
• Clinicians should not use conventional or biologic disease-modifying antirheumatic drugs for the treatment of hand OA.
• Clinicians should consider surgery in patients with structural abnormalities if other treatment methods have not been sufficiently effective in relieving pain. Consider trapeziectomy in patients with thumb base OA and consider arthrodesis or arthroplasty in patients with interphalangeal OA.
• Clinicians should adapt long-term follow-up of patients with OA based on individual patient needs.

The task force also developed a research agenda for topics relating to hand OA. They recommend placebo-controlled trials for a variety of hand OA treatments, including orthoses, topical NSAIDs, paracetamol, tramadol, glucosamine, chondroitin sulfate, intra-articular glucocorticoids, methotrexate, and low-dose oral glucocorticoids. Additional trials should be performed to assess the most effective types of exercise and surgery for hand OA.

The task force predicts that an update to these new recommendations may happen in the near future. “Advances in research of OA pathophysiology as well as outcome measurement increase the likelihood of finding new therapeutic options,” the researchers wrote. “The next update should be undertaken when sufficient new data are available, either on the current treatment options, or on new therapies.”

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Reference

Kloppenburg M, Kroon FPB, Blanco FJ, et al. 2018 update of the EULAR recommendations for the management of hand osteoarthritis [published online August 28, 2018]. Ann Rheum Dis. doi:10.1136/annrheumdis-2018-213826