EXTENDED REPORT

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 Zhang¹, M Doherty¹, B F Leeb², L Alekseeva³, N K Arden⁴, J W Bijlsma⁵, F Dinçer⁶, K Dziedzic⁷, H J Häuselmann⁸, G Herrero-Beaumont⁹, P Kaklamanis¹⁰, S Lohmander¹¹, E Maheu¹², E Martín-Mola¹³, K Pavelka¹⁴, L Punzi¹⁵, S Reiter¹⁶, J Sautner², J Smolen¹⁷, G Verbruggen¹⁸, I Zimmermann-Górska¹⁹

¹ Academic Rheumatology, University of Nottingham, Nottingham, UK
² 2nd Department of Medicine, Lower Austrian Centre for Rheumatology, Stockerau, Austria
³ State Institute of Rheumatology, Russian Academic Medical School, Moscow, Russian Federation
⁴ MRC Environmental Epidemiology Unit, Southampton General Hospital, Southampton, UK
⁵ Rheumatology and Clinical Immunology Department, University Medical Centre Utrecht, Utrecht, The Netherlands
⁶ Hacettepe University, Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Ankara, Turkey
⁷ Primary Care Musculoskeletal Research Centre, Keele University, Keele, UK
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 Department of Orthopaedics, Clinical Sciences Lund, Lund University, Lund, 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, Krankenhauz Lainz, Vienna, Austria
¹⁸ Department of Rheumatology, Ghent University Hospital, Gent, Belgium
¹⁹ Department of Rheumatology, Rehabilitation and Internal Medicine, University of Medical Sciences, Poznan, Poland

Correspondence to:
Dr W Zhang
Academic Rheumatology, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK; weiya.zhang{at}nottingham.ac.uk

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

Methods: The multidisciplinary guideline development group comprised 16 rheumatologists, one physiatrist, one orthopaedic surgeon, two allied health professionals, and one evidence based medicine expert, representing 15 different European countries. Each participant contributed up to 10 propositions describing key clinical points for 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 proposition. 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 (for example, clinical features, risk factors, comorbidities), non-pharmacological (for example, education plus exercise, local heat, and splint), pharmacological (for example, paracetamol, NSAIDs, NSAIDs plus gastroprotective agents, COX-2 inhibitors, systemic slow acting disease modifying drugs, intra-articular corticosteroids), and surgery. Of 17 treatment modalities, only six 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.

Abbreviations: ASU, avocado soybean unsaponifiables; CI, confidence interval; CT, controlled trial; CV, cardiovascular; ES, effect size; GI, gastrointestinal; MeSH, medical subject heading; NNT, number needed to treat; NSAIDs, non-steroidal anti-inflammatory drugs; PPIs, proton pump inhibitors; QALY, quality of life year; OA, osteoarthritis; OR, odds ratio; RCT, randomised controlled trial; RR, relative risk; SOR, strength of recommendation; SYSADOAs, symptomatic slow acting drugs for osteoarthritis; VAS, visual analogue scale

Keywords: EULAR; recommendations; hand osteoarthritis; treatment

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