Eular evidence based recommendations for the management of hand osteoarthritis - report of a task force of the Eular Standing Committee for International Clinical Studies Including Therapeutics(ESCISIT)

W Zhang ^1*, M Doherty ¹, B F Leeb ², L Alekseeva ³, N K Arden ⁴, J W Bijlsma ⁵, F Dincer ⁶, K Dziedzic ⁷, H J Häuselmann ⁸, G Herrero-Beaumont ⁹, P Kaklamanis ¹⁰, S Lohmander ¹¹, E Maheu ¹², E Martín-Mola ¹³, K Pavelka ¹⁴, L Punzi ¹⁵, S Reiter ¹⁶, J Sautner ¹⁷, J Smolen ¹⁸, G Verbruggen ¹⁹ and I Zimmermann-Górska ²⁰

¹ Nottingham University, United Kingdom
² 2 nd Dept. of Medicine Lower Austrian Center of Rheumatology, Austria
³ Russian Academic Medical School, Russian Federation
⁴ Southampton General Hospital, United Kingdom
⁵ Rheumatology and Clinical Immunology Department, University Medical Center Utrecht, Netherlands
⁶ Hacettepe University, Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Turkey
⁷ Primary Care Musculoskeletal Research Centre, Keele University, Keele, United Kingdom
⁸ Clinic Im Park Hirslanden Group, Centre for Rheumatology and Bone Disease, Zurich, Switzerland
⁹ Servicio de Reumatologia, Fundacion Jimenez Diaz, Madrid, Spain
¹⁰ 16, Anaperon Polemou St, Athens, Greece
¹¹ Lund University, Sweden
¹² Rheumatology, Hospital Saint-Antoine, Paris, France
¹³ Servicio de Reumatologia, Hospital Universitario La Paz, Madrid, Spain
¹⁴ Institute of Rheumatology, Na Slupi 4, Prague, Czech Republic
¹⁵ Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Padova, Italy
¹⁶ Rheumatology Unit, Federal Institute for Drugs and Medical Devices, Bonn, Germany
¹⁷ 2nd Department of Medicine, Lower Austrian Center for Rheumatology, Stockerau, Austria
¹⁸ Department of Medicine, Krankenhauz Lainz, Vienna, Austria
¹⁹ Department of Rheumatology, Ghent University Hospital, Gent, Belgium
²⁰ Department of Rheumatology, Rehabilitation and Internal Medicine, University of Medical Sciences, Po, Poland

^* To whom correspondence should be addressed. E-mail: weiya.zhang{at}nottingham.ac.uk.

Accepted 10 October 2006

Abstract

Objectives: To develop evidence based recommendations for the management of hand osteoarthritis (OA).

Methods: The multidisciplinary guideline development group comprised 16 rheumatologists, 1 physiatrist, 1 orthopaedic surgeon, 2 allied health professionals and 1 evidence based medicine expert, representing 15 different European countries. Each participant contributed up to 10 propositions describing key clinical points regarding management of hand OA. Final recommendations were agreed using a Delphi consensus approach. A systematic search of MEDLINE, EMBASE, CINAHL, Science Citation Index, AMED, Cochrane Library, HTA and NICE reports was used to identify the best available research evidence to support each of the propositions. Where possible the effect size and number needed to treat were calculated for efficacy. Relative risk or odds ratio was estimated for safety and incremental cost-effectiveness ratio was used for cost- effectiveness. The strength of recommendation was provided according to research evidence, clinical expertise and perceived patient preference.

Results: Eleven key propositions involving 17 treatment modalities were generated through three Delphi rounds. Treatment topics included general considerations (eg, clinical features, risk factors, co-morbidities), non-pharmacological (eg, education plus exercise, local heat and splint), pharmacological (eg, paracetamol, NSAIDs, NSAIDs plus gastroprotective agents, COX-2 inhibitors, systemic slow acting disease-modifying drugs, intra-articular corticosteroid) and surgery. Of 17 treatment modalities, only 6 were supported by research evidence (education plus exercise, NSAIDs, COX- 2 inhibitors, topical NSAIDs, topical capsaicin and chondroitin sulphate). Others were supported either by evidence extrapolated from studies of OA affecting other joint sites or by expert opinion. Strength of recommendation varied according to level of evidence, benefits and harms/costs of the treatment and clinical expertise.

Conclusion: Eleven key recommendations for treatment of hand OA were developed using a combination of research-based evidence and expert consensus. The evidence was evaluated and the strength of recommendation was provided.

Keywords: EULAR, hand osteoarthritis, treatment guidelines

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