No DMARDs or injections: EULAR’s 10 new recommendations on hand OA

EULAR describe it as the ‘forgotten disease’, and say guidelines developed for large joint OA cannot be extrapolated to hand OA.

In its first update of recommendations for the management of hand OA since their initial  publication in 2007, EULAR has provided new advice to reflect the emerging evidence for  drug and non-drug treatment options for hand OA.

The new recommendations, published in Annals of Rheumatic Diseases are:

  1. Education and training in ergonomic principles, pacing of activity and use of assistive devices should be offered to every patient
  2. Exercises to improve function and muscle strength, as well as to reduce pain, should be considered for every patient.
  3. Orthoses should be considered for symptom relief in patients with thumb base OA. Long-term use is advocated.
  4. Topical treatments are preferred over systemic treatments because of safety reasons. Topical NSAIDs are the first pharmacological topical treatment of choice.
  5. Oral analgesics, particularly NSAIDs, should be considered for a limited duration for relief of symptoms.
  6. Chondroitin sulfate may be used in patients with hand OA for pain relief and improvement in functioning.
  7. Intra-articular injections of glucocorticoids should not generally be used in patients with hand OA‡, but may be considered in patients with painful interphalangeal joints.
  8. Patients with hand OA should not be treated with conventional or biological disease-modifying antirheumatic drugs
  9. Surgery should be considered for patients with structural abnormalities when other treatment modalities have not been sufficiently effective in relieving pain. Trapeziectomy should be considered in patients with thumb base OA and arthrodesis or arthroplasty in patients with interphalangeal OA.
  10. Long-term follow-up of patients with hand OA should be adapted to the patient’s individual needs.

To accompany the recommendations, EULAR also provides a series of overarching principles on goals of treatment, information and education, shared decision making, individualisation of treatment and the importance of a multidisciplinary approach to hand OA.

The authors say the paucity of clinical trials in hand OA has meant that previous recommendations tended to be based more on expert opinion rather than  high level evidence. However almost all the new recommendations are base on evidence from RCTs (level 1b), they note.

“In recent years, hand OA has attracted more attention, and new data have become available on several pharmacological and non-pharmacological treatments, including but not limited to: self-management, application of thumb base orthoses, topical NSAIDs, oral corticosteroids, various intra-articular therapies and treatment with conventional synthetic and biological disease-modifying antirheumatic drugs (cs/bDMARDs), for example, hydroxychloroquine and TNF inhibitors,” says lead author Professor Margaret Kloppenburg of Leiden Univeristy, Netherlands.

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