Doctor… how is osteoarthritis of the hand treated… are there guidelines?

Recent guidelines by the European League Against Rheumatism (EULAR) issued evidence-based recommendations for treatment of hand osteoarthritis (OA).  The guidelines were published in the October 17 Online First issue of the Annals of the Rheumatic Diseases. The authors note that hand OA is a commonly undetected condition, but one that causes significant disability.

"Hand osteoarthritis (OA) is a common condition though its prevalence varies according to the definition used," states W. Zhang, MD, from Nottingham University in the United Kingdom, and colleagues from the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). "For example, the majority of people aged 55 years and over have radiographic changes of OA affecting at least one hand joint while approximately one fifth of this population have symptomatic hand OA.... Although many people affected by hand OA may never seek medical advice, the impact of hand OA and associated disability is significant."

Many of the clinical problems affecting activities of daily living are site specific, such as interference with grip and fine precision pinch and dissatisfaction with cosmetic appearance. In addition, the small size and accessibility of hand joints allow a different range of interventions than in large joint OA.

Because of differences in anatomy, function, risk factors and outcomes, OA at different sites may also respond differently to the same treatment. The published guidelines are as follows:

• Optimal management of hand OA requires a combination of non drug and drug treatment modalities individualized for each patient.
• Therapy of hand OA should be individualized based on the localization of OA; risk factors (age, sex, adverse mechanical factors); type of OA (nodal, erosive, traumatic); presence of inflammation; severity of structural change; level of pain, disability and restriction of quality of life; co-morbidity and co-medication (including OA at other sites); and patient wishes and expectations. (Author’s note: In a nutshell, what works for a grandmother who enjoys knitting might not work for a longshoreman)
• All patients with hand OA should receive education concerning joint protection (how to avoid adverse mechanical factors) together with an exercise regimen (involving both range of motion and strengthening exercises).
• Local application of heat (with paraffin wax or hot pack), especially before exercise, and ultrasound are helpful.
• Splints are recommended for thumb base OA, as well as orthoses to prevent or correct lateral angulation and flexion deformity.
• Local treatments are preferred over systemic treatments, especially for mild to moderate pain and when only a few joints are involved. Topical non-steroidal anti-inflammatory drugs (NSAIDs) and capsaicin are safe and effective. (Author’s note: we find Myorx to be an excellent topical agent at our center)
• Because of its efficacy and safety, paracetamol (up to 4 g/day) is the oral analgesic of first choice. It is the preferred long-term oral analgesic for patients who respond. (Author’s Note: paracetamol is not available in this country; a similar drug would be acetaminophen).
• In patients who respond inadequately to paracetamol, oral NSAIDs should be used at the lowest effective dose and for the shortest duration, and the patient's requirements and response to therapy should be reevaluated periodically. Patients with increased gastrointestinal risk should use nonselective NSAIDs plus a gastroprotective agent or a selective Cox-2 inhibitor. In patients with increased cardiovascular risk, Cox-2 specific inhibitors are contraindicated, and nonselective NSAIDs should be used with caution. (Author’s Note: the COX-2 controversy continues.  To date, cardiovascular risk appears to be a class effect involving all NSAIDS, not just COX-2 drugs).
• Symptomatic Slow-Acting Drugs for Osteoarthritis (eg, glucosamine, chondroitin sulphate, avocado soybean unsaponifiables, diacerhein, intra-articular hyaluronan) may offer symptomatic relief with low toxicity, but effect sizes are small, suitable patients are not defined, and clinically relevant structure modification and pharmacoeconomic benefits have not been established. (Author’s note: these alternative and novel therapies may be useful but patient selection is key. Individual response will vary.).
• Intra-articular injection of long-acting corticosteroid is effective for painful flares of OA, especially at the trapeziometacarpal joint. (Author’s note: injecting the small joints of the hand can be effective.  It is important that ultrasound needle guidance be used in order to assure proper placement of the needle).
• Surgery, such as interposition arthroplasty, osteotomy, or arthrodesis, is effective for severe thumb base OA and should be considered in patients with marked pain and/or disability after failure of conservative treatments.(Author’s note: arthroscopic debridement (cleaning out) can be effective in certain cases. [Wei N, Delauter SK, Beard SJ. Arthroscopic Debridement and Viscosupplementation: A Minimally Invasive Treatment for Symptomatic Osteoarthritis Involving the Base of the Thumb. J Clin Rheum. 2002; 8(3): 125-129].

OA of the hand continues to be s source of discomfort and debility for many patients.  Current research is being undertaken to solve this problem.