Hand osteoarthritis (HOA) is a common disorder frequently causing pain and impaired function with subsequent reduction in health-related quality of life. HOA is a very heterogeneous disease comprising several subsets, such as nodal interphalangeal (IP) OA, thumb base OA and erosive OA (EHOA). Although HOA was traditionally considered a mild disease, recent studies demonstrate that in at least 50% of patients the disease shows a radiographic progression at mid-term and in at least a quarter symptoms may persist. However, no association was seen between radiographic features and symptoms. EHOA is considered to be the most severe subset of HOA, with relevant clinical burden and worse outcome, which may evolves in joint instability and ankylosis, and subsequent disability. In keeping, EHOA is probably the subset in which prognosis may be better predicted.
Compared to other OA localisations, the management of HOA may be sometimes difficult, due to its great heterogeneity. Furthermore, the treatment may be influenced by many factors, including HOA subtypes, disease severity, disease duration, number of joints involved, affected site, age of patients, and occupational activities.
According with the EULAR recommendations three treatment modalities can been proposed: non-pharmacological, pharmacological, and surgical. In many patients these modalities should be combined, tailored to individual needs and risk factors.
Although non-pharmacological therapies are important in the management of HOA, high quality evidence is lacking. The exercise seems useful when combined with education and joint protection. Advice regarding the use of electrotherapy, thermotherapy, ultrasound, TENS or laser therapy is conflicting, mainly due to the lack of eligible studies. So, their inclusion in recommendations relies mainly on consensus methods and expert opinion.
As regard as the pharmacological therapy, the most realistic aim is the pain relief, due to limited evidence of reliable efficacy in modifying disease activity by drugs.
Among analgesics, paracetamol is considered as the first choice and, if successful, the preferred for long term, although evidence supporting its use in HOA are few. In mild to moderate pain and when not many joints are affected, topical treatments are a good option for many aspects, including the cost effectiveness. If paracetamol or topical NSAIDs are insufficient, then the addition of opioid analgesics should be considered, although the evidence supporting its use in HOA is poor.
In patients who respond inadequately to paracetamol or topical treatments, oral NSAIDs or COX-2 inhibitor should be used in substitution or in addition, possibly at lowest effective dose for the shortest period of time and taking into account individual patient risk factors, including age and comedications.
Intra-articular (IA) long-acting corticosteroid is effective for painful flares of OA, especially trapeziometacarpal joint (TMC) OA and so, it should be considered as an adjunct to core treatment for the relief of moderate to severe pain in people with HOA. There are contrasting opinions on the usefulness of IA hyaluronan (HA) in all existing recommendations. However, in two recent trials it seems more favourable than IA steroids.
Disease modifying drugs for OA (DMOADs) are currently not available. Most studies have been performed with off-label drugs.
The EHOA is the HOA subset deserving main attention by new treatment strategies, due to its severity and poor outcome. So, anti-cytokines biologic agents have been tested in some pilot studies using s.c. anakinra, humira and IA infliximab, with sometimes good results.
Surgery is uncommonly performed in HOA, and evidence for its effectiveness is lacking. However, for HOA at the base of the thumb, evidence does support effectiveness of surgical therapy when conventional therapies have failed. These surgical interventions include trapeziectomy, arthrodesis, osteotomy, ligament reconstruction, and joint replacement. Surgery for areas other than the thumb base is not yet widely available as a treatment option.
Disclosure of Interest None declared
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