New Recommendations for Hand Osteoarthritis Released

Janis C. Kelly

September 07, 2018

The 2018 update of recommendations for the management of hand osteoarthritis (OA) from the European League Against Rheumatism (EULAR) incorporate new evidence developed during the last decade, emphasizing the role of the patient in the OA treatment plan and the importance of multimodal/multidisciplinary therapy.

Margreet Kloppenburg, MD, PhD, from the Department of Rheumatology and the Department of Clinical Epidemiology; Féline P.B. Kroon, MD, PhD student, from the Department of Rheumatology, all at Leiden University, the Netherlands, and colleagues published their findings online August 28 in the Annals of the Rheumatic Diseases.

The recommendations add a new emphasis on optimizing and maximizing symptom control (rather than "joint protection") and modify previous guidance on patient education and treatment individualization.

EULAR recommends topical nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line pharmacologic treatment for hand OA. This differs from previous EULAR guidance and from the 2012 American College of Rheumatology recommendations. EULAR also recommends education about ergonomic principles, activity pacing, use of assistive devices, and exercises to improve function and muscle strength as the initial steps in managing hand OA, with or without topical NSAIDs.

The EULAR update recommends against using conventional or biologic disease-modifying antirheumatic drugs in hand OA and discourages the use of heat therapies, ultrasound, most intra-articular glucocorticoid injections, Symptomatic Slow Acting Drugs for Osteoarthritis (avocado, soybean unsaponifiables, diacerein, and intra-articular hyaluronan), and osteotomy.

Although the authors warn that the recommendations cannot be correctly interpreted without the accompanying text, and that the text and the separately published systematic literature review "form an integral part, and should be considered together," that review has not yet been published.

How EULAR and American College of Rheumatology Recommendations Compare

Roy D. Altman, MD, professor of medicine, Division of Rheumatology and Immunology, University of California, Los Angeles, told Medscape Medical News the updated EULAR guidance is more complete than the earlier American College of Rheumatology recommendations (of which he was a coauthor).

Altman said, "What is new is that the EULAR panel developed a set of principles including the role of the patient and multimodal therapy. Heat and paraffin are out. Topical NSAIDs have replaced acetaminophen as first-line treatment. Indeed, acetaminophen is a very weak recommendation. Chondroitin sulfate is recommended, and biologic therapy is specifically not recommended. Intra-articular therapy continues to have a limited role, and surgery is for relieving pain, not for restoring function." Altman was not involved in developing the EULAR update.

The authors delineate five overarching principles for hand OA care, within which their 10 recommendations fit. These were developed by a working group that for the first time included two patients with hand OA as well as 10 rheumatologists, one plastic surgeon, and three professionals in the field of physiotherapy and occupational therapy.

The first and key principal is that the goal of hand OA treatment is to control symptoms and optimize hand function to maximize activity, participation, and quality of life. The authors write, "The wording 'optimise' and 'maximise' were chosen to reflect that management of hand OA should be more ambitious than merely aiming for a patient-acceptable symptom state."

The update advises that patient education include information on the nature and course of OA, self-management principles, ergonomics, pacing of activity, use of assistive devices, and other treatment options.

When to Refer Hand OA for Specialist Care

The EULAR update identifies several situations in which referral to a rheumatologist or other joint specialist might be appropriate. These include the patient with thumb-base OA who needs an orthosis. The update advises having a well-fitted orthosis custom-made by a specialized health professional.

Referral for surgery is suggested for patients with hand OA who have structural abnormalities when other treatments have failed. The authors define treatment failure as "not sufficiently effective in relieving pain," and surgery is judged to be effective for relieving pain, but not for improving function.

The update advises considering simple trapeziectomy for thumb-base OA and arthrodesis or arthroplasty for interphalangeal OA. The authors write, "Arthroplasty (typically silicone implants) is the preferred surgical technique for the proximal interphalangeal (PIP) joints, with the exception of PIP-2, for which arthrodesis may be considered. Arthrodesis is the recommended approach for the distal interphalangeal joints."

Osteotomy is now considered "obsolete" for treating hand OA. Postoperative rehabilitation is recommended for all patients with hand OA treated with surgery.

A third situation calling for referral is for the relatively few patients who are candidates for intra-articular glucocorticoids, particularly those with painful interphalangeal joints with clear joint inflammation. The authors write, "Injections in small finger joints are preferably performed by a rheumatologist."

Altman added, "I find the paper helpful, and I have no disagreements. However, we still need new approaches and new agents."

The study was funded by EULAR. Several authors report multiple types of financial relationships with numerous companies. For the full disclosure please see the journal website. Altman has disclosed no relevant financial relationships.

Ann Rheum Dis. Published online August 28, 2018. Abstract

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