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EULAR Recommends Against Treating Hand OA With Conventional, Biologic DMARDs
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EULAR has for the first time updated its 2007 recommendations for the management of hand osteoarthritis, including a new warning against treatment with conventional or biological disease-modifying antirheumatic drugs. The update was published in the Annals of the Rheumatic Diseases.
“For a long time, hand OA was a ‘forgotten disease’, resulting in a paucity of clinical trials to guide recommendations, and therefore many of the propositions of previous recommendations were based mainly on expert opinion,” Margreet Kloppenburg, MD, PhD, of the Leiden University Medical Center in the Netherlands, and colleagues wrote. “However, in recent years, hand OA has attracted more attention, and new data have become available on several pharmacological and non-pharmacological treatments, including but not limited to: self-management, application of thumb base orthoses, topical [NSAIDs] oral corticosteroids, various intra-articular therapies and treatment with conventional synthetic and biological [DMARDs] for example, hydroxychloroquine and [TNF] inhibitors.”
To update the recommendations, EULAR formed a task force of 19 experts from 10 European countries. The task force members included Kloppenburg as the convener, a methodologist, a fellow, 10 rheumatologists, one plastic surgeon, three health care professionals in the field of physiotherapy and occupational therapy and two patient research partners.
Members of the task force conducted a systematic literature review of evidence regarding all non-pharmacological, pharmacological and surgical treatment therapies for hand OA published to date. In addition, prior to meeting, the experts completed an online survey regarding topics that should be covered in the update. Based on the literature review and the survey responses, members of the task force developed a series of overarching principles and recommendations.
Kloppenburg and colleagues established a total of five overarching principles and 10 recommendations. All five overarching principles and two of the 10 recommendations are new to the 2018 update. The first new recommendation warns rheumatologists against treating hand OA with conventional or biologic DMARDs. Instead, in a reiteration of the 2007 recommendations, the task force encouraged the use of topical therapies over systemic treatments due to safety reasons. In addition, they suggest that physicians use topical NSAIDs as the first pharmacological topical treatment of choice. The other new recommendation encourages physicians to tailor long-term follow-up to the individual patient’s needs. Lastly, the task force deleted an item from the 2007 recommendations concerning the use of heat and ultrasound.
The task force’s five overarching principles for the management of hand OA are:
- The primary goal of treatment is to control symptoms and optimize hand function, as well as to increase activity and quality of life;
- Providers should provide all patients with information regarding the nature and course of hand OA, as well as education on self-management and treatment options;
- Treatment should be adapted to each individual patient, considering severity, localization and comorbidities;
- Treatment should be based on shared decision-making between the provider and the patient; and
- Optimal management requires a multidisciplinary approach, and as such, pharmacological, nonpharmacological and surgical options should be considered.
“Although a relatively long period passed between the first set of recommendations and the current update, it is expected that the next update of the recommendations may be needed sooner, as the field of hand OA is growing,” Kloppenburg and colleagues wrote. “Advances in research of OA pathophysiology, as well as outcome measurement, increase the likelihood of finding new therapeutic options. The next update should be undertaken when sufficient new data are available, either on the current treatment options, or on new therapies.” – by Jason Laday
Disclosure: Kloppenburg reports funding from EULAR. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Andrew J. Laster, MD, FACR, CCD
When the ACR published recommendations for the use of non-pharmacologic/pharmacologic therapies in osteoarthritis (OA) of the hand, hip and knee in 2012, the section on hand OA covered less than one page of the manuscript. The 2018 EULAR update of 10 recommendations for the management of hand OA vastly expands on their 2007 recommendations and reflects the significant increase in studies devoted to hand OA in the last 5-10 years.
Though some may debate the methodology employed (modified Delphi for EULAR vs. GRADE for ACR) or the exact composition of the assembled task force, practicing rheumatologists will find a wealth of information here that may well challenge how they manage this common disease.
New to the 2018 report are “overarching principles,” not previously provided in the 2007 EULAR report, of which there are five. Shared decision-making between the patient and health professional is one of the overarching principles and, in fact, two of the 16 task force members were patients. The report also stressed a multidisciplinary approach including educating patients on self-management principles and treatment options.
One of the most significant differences with the 2012 ACR report relates to recommendations on the use of NSAIDs; topical NSAIDs were preferred over oral NSAIDs as the first pharmacologic treatment regardless of patient age with comparable efficacy and low rate of adverse effects even among those at high risk for cerebrovascular and cardiovascular disease. In comparison, the ACR expressed no preference for topical vs. oral NSAIDs among those aged < 75 years and conditionally recommended topical over oral NSAIDs among those aged > 75 years.
The 2018 EULAR reports states that use of oral NSAIDs could be considered in those with a large number of joints involved, but should be used at lowest effective dose for the shortest possible time. Ironically, a significant hurdle for more widespread use of topical NSAIDs in the United States relates to their higher cost to patients when compared with many oral NSAIDs.
Other topical treatments, including capsaicin and heat, demonstrated only “questionable efficacy” or “weak and conflicting evidence for a possible beneficial effect” — thus, heat is dropped from the 2018 recommendations. A single well-controlled trial supports the use of chondroitin sulfate, but there is no data in hand OA that indicates a benefit for glucosamine sulfate; therefore, chondroitin is recommended but glucosamine is only “suggested”. The benefit of acetaminophen was felt to be “uncertain” and no trials have been performed using tramadol for hand OA.
Long term use of oral glucocorticoids is not recommended with equivocal evidence for short-term use. No studies support the use of either conventional or biologic DMARDs including an absence of data for use of hydroxychloroquine to prevent structural damage.
Among the non-pharmacologic options, a well-fitted orthotic for thumb base OA — when used for more than 3 months — has been shown to reduce pain with slight improvement in function but no benefit for grip strength. No trial data is available for orthoses of other affected hand joints. Intra-articular injections of steroids were not supported for thumb base OA, but might relieve pain for interphalangeal joints. One can find additional recommendations regarding long-term care, surgery and areas of future research interest.
The reader of the 2018 EULAR report on hand OA is left with the realization that unlike the systemic autoimmune diseases that we often treat, recommendations for OA may differ greatly based on the anatomic location of the affected joint. However, just like those systemic diseases, collaborative efforts with other health care providers may maximize patient outcomes.
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