Hand Osteoarthritis - Treatment Recommendations

Symptomatic hand osteoarthritis affects 20 percent of people over 55 years of age. A EULAR (The European League Against Rheumatism) task force which previously released recommendations for the treatment of hip and knee osteoarthritis, released guidelines in 2006 for the treatment of hand osteoarthritis.

The EULAR task force, comprised of 21 experts including several rheumatologists, an orthopedic surgeon, and a physiatrist among other health professionals, analyzed evidence-based research and came to a consensus that 11 recommendations based on 17 treatment modalities was most appropriate for the treatment of hand osteoarthitis. These recommendations ranged from strongly recommended to weakly recommended depending on the level of evidence. It was noted that only 6 of the 17 treatment modalities were based on research evidence. Other recommendations were based on clinical expertise or data derived from osteoarthritis studies of joints other than the hand.

The EULAR task force has presented these recommendations for managing and treating hand osteoarthritis:

• A combination of pharmacologic (drug) and non-pharmacologic (non-drug) treatments, individualized for the hand osteoarthritis patient, is recommended.

• Therapy for hand osteoarthritis should be individualized for the patient. Risk factors, type of osteoarthritis, level of inflammation, pain level, severity, disability, quality of life, comorbidity, and co-medication should all be considered along with the patient's wishes.

• Patients should be educated about joint protection and given an exercise regimen.

• Heat application (e.g. hot pack, heating pad, paraffin wax) and ultrasound are helpful for management of osteoarthritis of the hand.

• For the base of the thumb, splinting is recommended. Orthotics are recommended to prevent certain other deformities.

• For mild to moderate pain and when not many joints are affected, local or topical treatments (e.g. topical NSAIDs, capsaicin) are better than systemic treatments.

• Acetaminophen (e.g., Tylenol) is the recommended oral analgesic. Up to 4 g/day is considered safe and effective.

• For patients who get an unsatisfactory response from acetaminophen, the next choice is oral NSAIDs (nonsteroidal anti-inflammatory drugs) at the lowest effective dose, for the shortest duration possible. The choice of NSAID for each individual patient must take into account gastrointestinal risk and cardiovascular risk.

• Glucosamine and chondroitin, avocado soybean unsaponifiables, diacerein, and viscosupplementation are all slow-acting treatments for osteoarthritis. They may offer relief with low toxicity.

• Intra-articular corticosteroid injections are effective, especially during bouts of painful osteoarthritis.

• Surgery (e.g., arthroplasty, arthrodesis, or osteotomy) can be considered for patients who had no luck with more conservative treatments. Surgery is recommended for patients with severe pain and disability from hand osteoarthritis.

Osteoarthritis impacts hands, hips, and knees differently. The joints are different in terms of anatomy and function, and patients are different in terms of appropriateness of treatment and response to treatment.

Six of the 11 recommendations, in the report which appeared in the Annals of the Rheumatic Diseases, were supported by study data:

• education and exercise
• NSAIDs
• COX-2 inhibitors
• topical NSAIDs
• topical capsaicin
• chondroitin sulfate

In 2012, the American College of Rheumatology updated recommendations for treating hand osteoarthritis. They conditionally recommended that doctors do the following for non-drug treatments:

• Evaluate the ability to perform activities of daily living (ADLs)
• Instruct in joint protection techniques
• Provide assistive devices, as needed, to help patients perform ADLs
• Instruct in use of thermal modalities
• Provide splints for patients with trapeziometacarpal  joint osteoarthritis

Conditional pharmacologic recommendations included the following (use one or more of the following):

• Topical capsaicin
• Topical NSAIDs, including trolamine salicylate
• Oral NSAIDs, including COX-2 selective inhibitors
• Tramadol

ACR conditionally recommended that health professionals not use the following:

• Intra-articular therapies
• Opioid analgesics

Also, patients who are 75 years old should use topical rather than oral NSAIDs.