Newly released recommendations from EULAR for the treatment of hand osteoarthritis (OA) constitute the first update to the 2007 recommendations and instruct clinicians to treat hand OA with exercises, orthoses, chondroitin sulphate and topical NSAIDs. Glucocorticoids are to be used only in specific cases, and biologic therapeutics should not be used at all.

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The update is important, as the 2012 ACR guidelines are focused on large joint OA, and the earlier 2007 EULAR hand-specific OA recommendations consist primarily of consensus by expert opinion owing to limited clinical trial data at the time. Since then, a much wider variety of pharmacological (for example, biologic and conventional synthetic DMARDs, NSAIDs and oral corticosteroids) and non-pharmacological therapies (for example, thumb orthoses) have been tested and included.

As such, the 2018 EULAR recommendations consist of 5 new overarching principles and 10 reformulated recommendations for the treatment of hand OA.

The guidelines were created using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) method, following on from a systematic literature review and culminating in a single-day meeting of 10 rheumatologists, a plastic surgeon and 3 occupational and physiotherapy experts.

For the first time, the panel also included 2 patient research partners. “This addition is an important improvement, since patients are one of the important target-users of these recommendations, and in evidence-based clinical decision making the patient perspective is valued as equally important to research evidence and clinical expertise,” says Margreet Kloppenburg, corresponding author of the study.

The 5 overarching principles agreed upon advocate treating hand OA to maximize functionality and minimize pain, and to engage in a multi-pronged approach to therapy that includes patient self-management and a focus on non-pharmacological options.

The 10 recommendations include hand exercises, application of chondroitin sulphate, long-term use of orthoses, topical NSAID application rather than systemic treatment and generally limited use of all oral analgesics.

Arguably the most important new addition, however, is the recommendation for complete avoidance of both conventional and biologic DMARDs for patients with hand OA.

“In clinical practice, conventional synthetic DMARDs or even biologic DMARDs are prescribed occasionally, especially to patients with severe inflammatory or erosive OA,” clarifies Kloppenburg regarding this new recommendation. “However, in recent years several studies have emerged that demonstrated that these DMARDs are not effective. Trials investigating the efficacy of hydroxychloroquine, anti-IL-1 and different TNF inhibitors could not demonstrate efficacy of these anti-rheumatic drugs in patients with hand OA.”

Some limitations of the new recommendations persist, however, as evidence is lacking as to which type of orthosis is best, plus the recommendation that patients with structural abnormalities have surgery when other options fail to relieve pain is still mostly a result of expert opinion and not supported by surgical trial data.

Furthermore, the strength of the recommendations regarding avoidance of treatment with glucocorticoids is not entirely clear owing to limited clinical data.

“The recommendation ‘should not generally be used’ was chosen, as the task force recognised that in specific cases where, for example, clear joint inflammation is present, intra-articular injection with glucocorticoids may still be a therapeutic option, “says Kloppenburg.

…the 2018 EULAR recommendations consist of 5 new overarching principles and 10 reformulated recommendations…

Nancy E. Lane, an OA expert who is not on the new paper, also cautions that there is variability in the number of joints affected by OA and that subgroups or phenotypes of hand OA exist that might confuse some of the recommendations. “These recommendations appropriately recommend non-pharmacological therapy before pharmacological treatments for hand OA,” she says “but we need to spend more time studying the disease and finding more effective treatments — this is a call to arms for hand OA.”