2018 Update of the EULAR recommendations for the management of hand OA
| LoE* | GoR† | LoA (0–10) | ||
| Overarching principles | ||||
| A. | The primary goal of managing hand OA is to control symptoms, such as pain and stiffness, and to optimise hand function, in order to maximise activity, participation and quality of life. | 9.7 (0.7) | ||
| B. | All patients should be offered information on the nature and course of the disease, as well as education on self-management principles and treatment options. | 9.8 (0.8) | ||
| C. | Management of hand OA should be individualised taking into account its localisation and severity, as well as comorbidities. | 9.9 (0.2) | ||
| D. | Management of hand OA should be based on a shared decision between the patient and the health professional. | 9.6 (1.1) | ||
| E. | Optimal management of hand OA usually requires a multidisciplinary approach. In addition to non-pharmacological modalities, pharmacological options and surgery should be considered. | 9.3 (1.2) | ||
| Recommendations | ||||
| 1. | Education and training in ergonomic principles, pacing of activity and use of assistive devices should be offered to every patient. | 1b | A | 9.3 (1.1) |
| 2. | Exercises to improve function and muscle strength, as well as to reduce pain, should be considered for every patient. | 1a | A | 9.1 (1.6) |
| 3. | Orthoses should be considered for symptom relief in patients with thumb base OA. Long-term use is advocated. | 1b | A | 9.3 (1.0) |
| 4. | Topical treatments are preferred over systemic treatments because of safety reasons. Topical NSAIDs are the first pharmacological topical treatment of choice. | 1b | A | 8.6 (1.8) |
| 5. | Oral analgesics, particularly NSAIDs, should be considered for a limited duration for relief of symptoms. | 1a | A | 9.4 (0.9) |
| 6. | Chondroitin sulfate may be used in patients with hand OA for pain relief and improvement in functioning. | 1b | A | 7.3 (2.7) |
| 7. | Intra-articular injections of glucocorticoids should not generally be used in patients with hand OA‡, but may be considered in patients with painful interphalangeal joints§. | 1a‡–1b§ | A | 7.9 (2.4) |
| 8. | Patients with hand OA should not be treated with conventional or biological disease-modifying antirheumatic drugs | 1a | A | 8.8 (1.8) |
| 9. | Surgery should be considered for patients with structural abnormalities when other treatment modalities have not been sufficiently effective in relieving pain. Trapeziectomy should be considered in patients with thumb base OA and arthrodesis or arthroplasty in patients with interphalangeal OA. | 5 | D | 9.4 (1.4) |
| 10. | Long-term follow-up of patients with hand OA should be adapted to the patient’s individual needs. | 5 | D | 9.5 (1.7) |
*1a: systematic review of RCTs; 1b: individual RCT; 2a: systematic review of cohort studies; 2b: individual cohort study (including low-quality RCT; eg,<80% follow-up); 3a: systematic review of case-control studies; 3b: individual case-control study; 4: case-series (and poor quality cohort and case-control studies); 5: expert opinion without explicit critical appraisal, or based on physiology, bench research or ‘first principles’.17
†A: based on consistent level 1 evidence; B: based on consistent level 2 or 3 evidence or extrapolations from level 1 evidence; C: based on level 4 evidence or extrapolations from level 2 or 3 evidence; D: based on level 5 evidence or on troublingly inconsistent or inconclusive studies of any level.17
EULAR, European League Against Rheumatism; GoR, grade of recommendation; LoA, level of agreement; LoE, level of evidence; NSAIDs, non-steroidal anti-inflammatory drugs; OA, osteoarthritis; RCT, randomised clinical trial.