2 July 2018

Handy guidelines: what’s new for OA management

Clinical Rheumatology

Intra-articular injections of glucocorticoids and DMARDs are both off the menu for patients with hand osteoarthritis, according to new international rheumatology guidelines. 

The guidelines, aimed at general practitioners and allied health professionals, as well as rheumatologists, suggest that while patients with painful interphalangeal joints may benefit from the steroid injections, there is no evidence to suggest it is beneficial in the thumb base. 

This is an about-face from the previous 2007 guidelines, in which expert opinion advised clinicians to use them in the case of painful flares, particularly in the thumb base.

More than 100 studies were used as the basis for the new guidelines, which were presented at the European League Against Rheumatism (EULAR) conference in Amsterdam last month.

 Patient education, symptom control, shared decision-making and individualised treatment with a range of modalities are the overarching themes of the new recommendations.

In addition to the principles, the document spelled out 10 specific recommendations in the treatment of the condition, Dr Féline Kroon, from the Department of Rheumatology Leiden University Medical Centre, said. 

This included the need to educate patients on ergonomic principles and to offer every individual assistive devices. However, Dr Kroon did include the caveat that there was no evidence to support more intensive programs over simpler ones. 

“Exercises to improve function and muscle strength, as well as to reduce pain, should be considered for every patient,” Dr Kroon said, citing evidence from several recent studies. 

“However, the studies on exercise interventions were heterogeneous and that is why the taskforce cannot recommend a certain exercise regimen,” she said.

“Moreover, it is important to note that the benefits of exercise regimens were not sustained after the patient stopped exercising.”

New evidence from multiple trials also came in support of orthosis, or splints, for symptom relief in patients with thumb-base osteoarthritis. While no specific recommendations could be given for the design or type of device, Dr Kroon said that it was important for patients to use them for at least three months to improve pain, and to a lesser extent, function. 

When it came to pharmacologic therapy, topical NSAIDs were the first-line treatment. Safety issues were the number one driving force behind this treatment, but systemic treatments could be considered among patients with multiple joints affected, she said. 

The taskforce dropped previous 2007 recommendations about using hot or cold applications, saying these lacked a strong evidence base.

When it came to oral NSAIDs, Dr Kroon said the advice was much the same as a decade ago. 

“Oral NSAIDs should be prescribed at the lowest effective dose, for a limited duration, and preferably on-demand, with attention to risk benefit ratio,” she said. Clinicians should opt for topical treatments over oral ones, given hand osteoarthritis was often a local disease, and the safety concerns around oral NSAID use. 

In response to a question from the audience, Dr Kroon said there was no specific data indicating any NSAID, such as ibuprofen or diclofenac, was superior to another. 

While the taskforce found small safety signals in the use of paracetamol, “the taskforce thought that the clinical relevance of these signals are doubtful, and that paracetamol may thus be prescribed”, but preferably only for a limited time and in select patients, such as in those for whom oral NSAIDs were contraindicated.

Dr Kroon said there were currently no drugs with “disease modifying” properties available.

One good study found improvements in pain relief and functioning from chondroitin sulphate for hand osteoarthritis, but others in knee and hip patients had been less promising, so at this stage use of the therapy was only a suggestion. Similarly, no other nutraceuticals had a solid evidence base. 

Research had recently found no benefit from cs/bDMARDs in these patients, and Dr Kroon said that the basis for oral glucocorticoid use was still equivocal, “and at this moment also no reason to prescribe these drugs for prolonged periods of time” 

In the experts’ opinion, surgery could be considered in patients with structural abnormalities as a last resort for pain relief. 

From there, long-term management should be tailored to the individual, taking into mind their wants and expectations, symptom severity, erosive disease and medication use.