Managing Hand Osteoarthritis

Summarized by Robert W. Griffith, MD
January 22, 2007

Summary

Sixteen rheumatologists from 15 European countries have listed 11 evidence-based recommendations for the treatment of osteoarthritis of the hands, which affects as many as 1 in 5 adults.

Introduction

As many as one in five people over 55 have symptoms of osteoarthritis of the hands, while nearly everyone in this age group has radiographic signs of arthritis in one or more hand joints. The disease causes problems with grip and precision movements, as well as producing visible deformity. Most sufferers don't seek medical advice, contenting themselves with over-the-counter analgesics like ibuprofen (Advil^®) or acetaminophen (Tylenol^®).

EULAR is the abbreviation for the European League Against Rheumatism, and the Annals of the Rheumatic Diseases is its official journal. A Standing Committee has issued an online report on evidence-based recommendations for managing hand osteoarthritis; it contains 11 key treatment approaches, which we summarize below.

What was done

The EULAR Committee studying this problem was composed of 16 rheumatologists, one physical therapist, 1 orthopedic surgeon, 2 related health professionals, and 1 evidence-based medicine expert; they came from 15 different European countries. A systematic search of published databases was done to identify the best available research evidence to support different management approaches. Committee members then suggested those treatments they felt to be effective; 150 were collected. Only 6 treatment regimes were supported by adequate research evidence:

• Education plus exercise
• Non-steroid anti-inflammatory drugs (NSAIDs), e.g. ibuprofen (Advil) or acetaminophen (Tylenol)
• COX-2 inhibitor drugs, e.g. celecoxib (Celebrex^®)
• Locally-applied NSAIDs
• Locally-applied capsaicin
• Chondroitin sulfate

The final set of recommendations were reached by a Delphi consensus method.¹

The 11 Committee recommendations

1. A combination of drug and non-drug treatments, individualized for each patient.
2. Individualization depends on localization of joint(s), type (nodal, erosive, traumatic), inflammatory changes, level of pain, disability etc., medications being taken, and patient wishes.
3. Education regarding joint protection and an exercise regimen.
4. Local heat (paraffin wax or hot pack) before exercise, and ultrasound.
5. Splints for thumb-based osteoarthritis, orthoses² as necessary.
6. Local treatments are preferred over systemic (e.g. oral) treatments. Topical NSAIDs and capsaicin are safe and effective.
7. Acetaminophen (Tylenol) is the best oral pain killer; take up to 4 grams a day.
8. If acetaminophen is inadequate, use other NSAIDs at the lowest effective dose, for as short a time as possible. If gastrointestinal side effects are a problem, add a proton-pump inhibitor (e.g. Prilosec^® or Nexium^®) or switch to a COX-2 inhibitor (e.g. Celebrex). Read the black-box warnings!
9. The following may prove slightly effective in some people: glucosamine, chondroitin sulfate, avocado/soybean unsaponifiables (ASU), diacerhein, and intra-articular injection of hyaluronic acid.
10. Intra-articular corticosteroids are effective for painful flare-ups.
11. Special surgical procedures (arthroplasty, osteotomy, arthrodesis) can be considered if conservative treatments have failed.

The Committee emphasize that the important differences between hands, knees, and hips means that their recommendations are not necessarily valid for sites of osteoarthritis other than the hands. They also deplore the lack of specific clinical research studies on the treatment of hand osteoarthritis.

Comment

This Committee's recommendations are valuable, the more so because they are accompanied by comments on the 'strength' of each - in other words, how good (or not) the available evidence supporting effectiveness and safety is. The absence of adequate clinical studies to support many of the recommendations is disappointing. Only well-conducted, well-controlled clinical trials can confirm the effectiveness of many supposed remedies. Patients with hand osteoarthritis are encouraged to volunteer for such studies.

Source

• Zang W, M Doherty, BF Leeb, et al. Eular evidence based recommendations for the management of hand osteoarthritis - report of a task force of the Eular Standing Committee for International Clinical Studies Including Therapeutics(ESCISIT). http://ard.bmj.com/cgi/content/abstract/ard.2006.062091v1

Footnotes
1. The Delphi technique is a method for obtaining forecasts (or policies) from a panel of independent experts over two or more rounds. Experts are asked to make predictions (or suggest approaches). After each round, an administrator provides an anonymous summary of the experts' views and their reasons for them. When experts' views have changed little between rounds, the process is stopped and the final-round suggstions are combined (or listed separately).
2. An orthosis is a device applied to a human limb to control or enhance movement or to prevent bone movement or deformity - e.g. a splint.

Related Links
Osteoarthritis of the Hands
Arthritis Foundation: OA of the Hands in the Elderly
Using Chopsticks a Risk Factor . . .

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