Our roundtable panelists offer their take on the recent EULAR guidelines for managing osteoarthritis (OA) in the hand and provide pertinent pearls from their clinical experience in treating OA hand pain.

Q: In regard to the recent Euro-pean League Against Rheumatism (EULAR) guidelines for symptomatic hand osteoarthritis (OA), was there anything that surprised you? Was there any aspect of the guidelines that might change your approach or your armamentarium in treating this condition?

A: All of the panelists agree that there were no surprises from the EULAR guidelines. Kiplee Bell, PA-C, notes she has been “employing these methods in my practice for years.”

Nathan Wei, MD, FACP, FACR, says the only disparity between the EULAR guidelines and what he does in his practice is the use of paracetamol, a European analgesic drug that is not used in the United States. He says the closest equivalent would be acetaminophen (Tylenol, J&J).

Linda Davis, PA-C, says she does not encourage the use of over-the-counter (OTC) nutriceuticals as there are no controls as to the quantity and percentage of particular compounds and fillers in each tablet or pill. Additionally, Davis says there are currently no head-to-head studies with prescription drugs and nutriceuticals to evaluate whether there is an increased risk of side effects when patients use these medications together.

She notes that a recently published review of glucosamine found a low incidence of adverse effects but questioned the efficacy.¹ A Cochrane Database review was published in 2005 on glucosamine, according to Davis, who adds that a similar review is underway to evaluate chondroitin for efficacy and possible adverse effects.² Davis and Bell agree that more studies are needed on nutriceuticals.

All of the panelists agree about the importance of tailoring the treatment regimen to the individual patient, and emphasize patient education.

“I reassure the patient that this is a disease of a relatively benign nature, albeit a chronic disease without a cure,” explains Davis. “I like to think of us as a team working for the same goal of allowing the patient to attain his or her desired quality of life.”

Accordingly, Davis emphasizes rest, avoidance of aggravating activity and lifestyle changes that can reduce the burden of pain for the patient. This could include physical therapy (PT) as well as occupational therapy (OT) to address ergonomic issues at home and work, according to Davis. Bell concurs, noting that she would like to see “more emphasis placed on the use of PT and OT as first-line therapy.”

Davis also emphasizes the benefits of a healthy diet and encourages patients to try to get vitamins and minerals from whole foods instead of supplements.

If a patient has hand OA and significant OA elsewhere, Dr. Wei will not hesitate to use systemic therapies such as nonsteroidal antiinflammatory drugs (NSAIDs). Dr. Wei encourages a thorough diagnostic workup in order to ensure the patient doesn’t have gout or other inflammatory forms of arthritis. As he points out, combined OA and rheumatoid arthritis (RA) is not that uncommon. Indeed, there is a need to evaluate for other concomitant issues that are secondary to OA, notes Davis, who cites pain control, depression, sleep disruption and other mitigating psychosocial issues that may come into play.

(Photo courtesy of the American College of Rheumatology) Here one can see osteoarthritis that reveals Heberden’s and Bouchard’s nodes. The European League Against Rheumatism (EULAR) recently issued guidelines for the treatment of symptomatic osteoarthritis in the hands.

Q: When patients have mild to moderate OA and not that many joints are affected, the EULAR guidelines seem to put more of an emphasis on local or topical treatments as opposed to systemic therapies. Have you found that to be the case in your clinical experience?

A: Often, monotherapy is only effective at the initial onset of symptoms according to Bell, who adds that most patients have likely tried many options before coming into the office. In her clinical experience, Bell has found that combining simple analgesia, muscle-strengthening physiotherapy, a thumb spica splint and intraarticular corticosteroid injections is particularly effective. Cortisone injections into sore joints “can be very helpful in controlling pain and swelling,” notes Bell.

When it comes to treating patients with hand OA and not that many joints are involved, Dr. Wei says “local therapies are probably the way to go.” All of the panelists cite the benefits of paraffin baths. Dr. Wei also notes that splints are usually effective.

There are different opinions about the merits of topical capsaicin. Bell cites OTC topical capsaicin concentrations of 0.025% and 0.075%. Dr. Wei believes topical capsaicin “is worth doing” and cites Myorx as a preferred topical agent. However, Davis tends to avoid topical capsaicin as she has had patients tell her that the burn of this modality is “worse than the pain of OA.”

Dr. Wei adds that complementary topical therapies, such as glucosamine/chondroitin or avocado soy, are “worth a try.”

While Davis prefers the use of systemic therapies in a stepwise manner, she has used the Lidoderm patch (Endo Pharmaceuticals) on occasion. As she points out, one can cut the patch to the size and shape of the most painful joint(s). However, Davis says the Lidoderm patch works better on larger joints than the small joints of the hand. Since it is topical, it does not interfere with the patient’s other medications and has minimal adverse effects, according to Davis. Yet she notes that insurance companies are reluctant to pay for off-label use of this modality for OA pain. (The Lidoderm patch is indicated for peripheral neuropathy pain from shingles.)

One may utilize OTC heat pads but Davis emphasizes appropriate precautions, especially when it comes to older patients with thin skin.

Q: What about exercise recommendations? Are there any
specific recommendations that you have found to be effective in patients with hand OA?

A: Davis says therapeutic hand massage by a certified massage therapist can be helpful. All of the panelists recommend the involvement of PT and OT specialists. The panelists note that occupational therapists can offer help and instruction when it comes to facilitating activities of daily living, the use of assistive devices and appropriate joint protection.

“A good hand therapist can design a specific exercise program for people with hand OA,” suggests Dr. Wei. “Keeping active is important. My mother-in-law knits and swears that keeps her hand OA in check.”

Bell says exercises that have aided in increased function and mobility include squeezing tennis or stress balls. Davis concurs, noting that she will give patients a spongy ball to exercise with throughout the day to keep the hands flexible.

Davis adds that occupation therapists can evaluate a patient’s job to see if possible reengineering of the job duties could help reduce aggravating factors and pain.

Q: At what point in your armamentarium for hand OA, would you consider intraarticular
corticosteroid injections? Are there any specific pearls you would pass along on either dosing or technique that might help facilitate optimal results?

A: When treating patients with one or two swollen painful joints, Dr. Wei says administering intraarticular steroids via ultrasound needle guidance is “very effective.” One may also utilize intraarticular hyaluronan following arthroscopic debridement for basal joint thumb OA, according to Dr. Wei.³ He adds that some patients with particularly severe, inflammatory OA involving one or two joints may respond to arthroscopic debridement of that joint if local steroid injection does not work.

Bell uses cortisone on a case-by-case basis and usually when there is one joint involved that is particularly tender, swollen and erythematous. She recommends the following pearls to maximize results:

• use good aseptic technique to reduce infection;
• avoid repeated injections around tendons and never inject corticosteroids into the body of a tendon to reduce the risk of subsequent rupture;
• do not use strong, long-acting crystalline preparations when injecting periarticular structures close to the skin as these can cause unsightly skin atrophy; and
• avoid repeated consecutive injections to reduce the risk of accelerated joint damage or osteonecrosis.

Davis says intraarticular corticosteroid injections are difficult to perform in the smaller joints and are painful for the patient. Accordingly, she reserves these injections as a last therapeutic option before surgery. However, Dr. Wei adds that in his experience, small joint injection is not difficult to perform and that it hurts no more than large joint injection.

Ms. Bell has a master’s degree in gerontology and enjoys serving the gero-rheumatology patient.
Ms. Davis has a master’s degree in health science as a physician assistant. She is an Assistant Professor of Rheumatology at the Texas College of Osteopathic Medicine and at the University of North Texas Health Science Center in Fort Worth, Tx.
Dr. Wei is a board-certified rheumatologist. He is the Clinical Director of the Arthritis and Osteoporosis Center in Frederick, Md.