Managing hand osteoarthritis – the latest evidence

Case scenario

A 53-year-old female presents to the pharmacy with diagnosed hand osteoarthritis. She currently uses a splint and has used a topical non-steroidal anti-inflammatory drug in the past but finds it inconvenient to apply at work. Her pain is flaring up again and she is seeking pain relief.

Introduction

Osteoarthritis (OA) is the most common form of arthritis in Australia, with an increasing prevalence among the ageing population.¹ OA most commonly affects the hands, knee, hip and spine, and is the predominant condition leading to knee and hip replacement surgery in Australia.¹

Guidelines for the management of OA have mainly focused on large joint OA (i.e. knee and hip). However, these recommendations cannot be readily extrapolated to other types of OA, such as hand OA, due to the differing functionality, risk factors and pathophysiological mechanisms of OA at different joint sites.²

Despite being one of the most common phenotypes with a high clinical burden, hand OA was long regarded as a ‘forgotten disease’, with limited clinical evidence to guide treatment recommendations.^2,3 In recent years, hand OA has attracted more attention, as emerging evidence has given fresh insights into treatment options.²

This CPD module will focus on the latest best practice management for hand OA, based on the 2018 update to recommendations from the European Alliance of Associations of Rheumatology (formerly known as EULAR).

Understanding the nuances in management of differing OA subtypes can help pharmacists to personalise care for their patients with OA.

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Pathogenesis and aetiology of hand OA

OA is an inflammatory disease characterised by progressive onset of joint damage, commonly associated with pain.⁴ Upregulation of inflammatory pathways results in the presence of cytokines and growth factors in the extracellular matrix of cartilage surrounding the affected joint.⁴ This can result in changes to the production of aggrecan, a highly negatively charged protein that helps give cartilage its compressive stiffness.⁴ Over time, the cartilage disintegrates, and bone marrow lesions can form which narrow the joint space and cause symptoms such as pain and stiffness.^2,4 

Several factors play a role in the aetiology of hand OA. Environmental factors, such as stress from mechanical loading, especially to vulnerable joints, predispose individuals to developing OA. Other risk factors for hand OA include age, gender, obesity, smoking, genetics, diet and occupation (Table 1).⁴ 

Table 1 – Risk factors for hand OA

* JSN: joint space narrowing. SNP: single nucleotide polymorphism. Adapted from Table 2, Leung et al 2013.⁴ 

Clinical presentation of hand OA

Patients with hand OA may present with pain in the hand joints, functional limitation and decreased grip strength. These symptoms can hinder the patient’s quality of life, as everyday tasks, such as writing or lifting objects, become challenging.⁴ Clinical hallmarks of the disease include bony enlargement and deformities of the hand joints, sometimes accompanied by soft tissue swelling.² Typically, both hands are affected, most commonly in the distal interphalangeal (DIP) joints, thumb bases, proximal interphalangeal (PIP) joints, and second and third metacarpophalangeal (MCP) joints.⁶

The clinical presentation differs between each subtype of hand OA⁶:

• Nodal OA is characterised by the presence of firm-hard bony swellings (Heberden/Bouchard nodes) and underlying interphalangeal OA. It most commonly occurs in middle-aged women, often with a family history of hand OA. Symptoms usually start in middle age, around menopause, and include a stuttering onset of pain, tenderness and stiffness in the finger interphalangeal joints. Over time, the pain and inflammation subside leaving behind Herberden/Bouchard nodes.
• Thumb-base OA is characterised by localised deep thenar, radial wrist or thumb-base pain that is exacerbated on joint use, usually during activities that involve pinching. A subjective grinding sensation on movement and/or swollen appearance of the thumb base may also be present. It generally affects older postmenopausal women.
• Erosive OA is an uncommon and aggressive subtype where pain, stiffness and soft-tissue swelling are more marked and prolonged. It mainly targets the interphalangeal joints (DIP more frequently than PIP) and is associated with worse outcomes in terms of symptom persistence and functional impairment.

Progression of hand OA can be a slow, ongoing process, but the disease course is highly variable.³ Erosive OA is associated with a higher clinical burden, whereas thumb-base OA may have more pain and disability than finger OA.³ A high level of baseline functional impairment and a greater number of painful joints increase the risk of adverse clinical outcomes.^3,6

Diagram 1 – Joints of the hand

Overarching principles of management

The management of hand OA primarily aims to manage symptoms and optimise hand function to achieve the best possible activity, performance, participation and quality of life (Table 2).² A core management strategy is the ongoing provision of patient education on the nature and course of disease, particularly in patients with chronic symptoms, as the information is reinforced and expanded upon over time. Focus group interviews have shown that hand OA patients often struggle to understand the impact of disease and perceive a lack of support and/or contradictory advice from healthcare professionals.³ Providing education to patients is an important role that trained health professionals like pharmacists can play.²

Since hand OA is a heterogenous disease, optimal management usually requires a multidisciplinary approach that combines both non-pharmacological and pharmacological intervention.² Management strategies should be individualised to the patient as OA localisation (e.g. finger versus thumb-base OA), severity of symptoms and presence of comorbidities can influence treatment decisions. Severity may include a high number of hand joints with OA, one or two severely affected joints, or acute joint inflammation due to OA.² 

Additionally, a shared decision-making approach should be taken to ensure both the healthcare professional and patient mutually share and consent to the preferred management strategy.² This can be achieved by building and maintaining a therapeutic relationship with the patient and sharing the best evidence to make an informed decision.²

Table 2 – The overarching principles for the management of hand OA

Adapted from Table 1, Kloppenburg et al 2019.²

Non-pharmacological interventions

Education on ergonomic principles, pacing of activity and use of assistive devices are important aspects of management that should be offered to every patient.² An assistive device is a piece of equipment that can increase, maintain or improve the functional capabilities of the patient, including orthoses such as a splint or ergonomic equipment.³ They are commonly used in hand OA and have been shown to improve a patient’s self-management of the disease.² Long-term use of orthoses may be required to relieve symptoms in patients with thumb-base OA.² Choosing a splint should be a shared decision with the patient, since there are no recommendations to use a particular type of splint.³ It is important to ensure the chosen orthoses is properly fitted to improve patient compliance and increase long-term use.²

Exercise has been shown to benefit pain and function, joint stiffness and grip strength while resulting in few and non-severe adverse effects.² Exercises should aim to improve joint mobility, muscle strength and thumb-base stability in a regimen that is specific to the disease location. For example, the first carpometacarpal (CMC–1) joints require different exercises to the interphalangeal joints.² In line with a multidisciplinary approach, patients can be referred to their physician/rheumatologist or a physiotherapist for guidance on appropriate exercises for them.

Pharmacological interventions

Treatment choice may depend on the number of joints affected.² For single joints, topical non-steroidal anti-inflammatory drugs (NSAIDs) may be an appropriate option to deal with flare-up pain and may be used in combination with assistive devices when pain is localised to the hand (Table 3).² Most NSAIDs work by reversibly inhibiting the enzyme cyclo-oxygenase (prostaglandin endoperoxide synthase or COX), which mediates the production of prostaglandins, thereby regulating the role of prostaglandins in inflammatory and pain processes.⁷ 

If several joints are affected, oral NSAIDs can be considered.² They were shown to improve pain and function after 2–4 weeks in three high-quality studies.² Paracetamol use, however, has been a topic of debate in hand OA due to its risk-benefit profile.² Evidence from two large meta-analyses showed that paracetamol was associated with an increased risk of liver test abnormalities, although the clinical relevance of this finding is undetermined and there was no increased risk in other safety parameters.² The efficacy of paracetamol in the treatment of hand OA is unknown and likely to be small, but there is no need to refrain from prescribing it for short durations in selected patients; for example, when oral NSAIDS are contraindicated.²

Other interventions with limited efficacy or uncertain benefit in hand OA include²:

• Glucosamine – not recommended due to a lack of evidence supporting its use in hand OA.²
• Chondroitin sulfate – may be used in hand OA for pain relief and improvement in functioning, though this is a suggestion rather than a recommendation due to limited evidence.² 
• Topical capsaicin – not routinely recommended due to limited evidence and association with frequent local adverse effects, including burning and stinging sensation.² It may be used as an additive analgesic if other therapies do not suffice or are contraindicated.³
• Intra-articular injections of glucocorticoids – should not be used in hand OA but may be considered in patients with painful interphalangeal joints.² 
• Conventional/biological disease-modifying antirheumatic drugs – not recommended for hand OA due to limited efficacy or no evidence (e.g. hydroxychloroquine, anti-interleukin-1, TNF-inhibitors).² 

Surgical interventions

Surgery should only be considered for patients with structural abnormalities when other treatment modalities have been insufficient to effectively relieve pain.² For example, trapeziectomy may be considered in patients with thumb base OA and arthrodesis or arthroplasty in patients with interphalangeal OA.²

Table 3 – Recommendations for the management of hand OA

Adapted from Table 1, Kloppenburg et al 2019.² *A: based on consistent level 1 evidence; D: based on level 5 evidence or on troublingly inconsistent or inconclusive studies of any level. ^†From an international taskforce of 19 physicians, healthcare professionals and patients from 10 European countries.

Considerations when using oral NSAIDs in hand OA

When oral NSAIDs are appropriate to relieve symptoms during a flare-up, they should be used at the lowest effective dose for the shortest duration, as adverse effects are dose dependent.⁸ This approach is vital to balancing efficacy and safety.⁸ Oral NSAIDs should only be initiated if the benefit outweighs the risk of treatment, especially in patients with a risk of gastrointestinal, cardiovascular or renal adverse effects.² 

Consider initiating oral NSAIDs in a stepwise approach that corresponds to the severity of pain and the individual needs of the patient. For mild to moderate hand OA, ibuprofen can provide effective pain relief that may last up to 8 hours,^9–11 while also having a similar gastrointestinal tolerability profile to paracetamol at over-the-counter doses, in patients without contraindications or precautions.^12,13 Modified-release ibuprofen formulations that provide 12-hour duration of effect are also available for patients that may benefit from a reduced dosing frequency or extended pain relief; for example, those who are not used to or struggle to take oral medication frequently. 

If the pain is not sufficiently managed with ibuprofen alone, or if the patient is reporting stronger pain from the outset, a combined formulation of ibuprofen with paracetamol may provide effective relief for moderate to severe pain, while also minimising the risk of adverse effects that would otherwise be associated with a dose increase.^7,11 This is supported by a multicentre, 2-stage, randomised, double-blind, parallel-group, placebo-controlled, factorial study in patients with moderate to severe postoperative dental pain, which showed that a fixed-dose combination of ibuprofen 200 mg/paracetamol 500 mg had significantly lower rates of treatment-related adverse events compared with ibuprofen 200 mg and paracetamol 500 mg alone (6.3% vs 16.0%; p<0.05 and 22.4%; p<0.001 respectively).¹¹

For moderate to severe pain, it may be more appropriate to initiate pharmacotherapy with a combination NSAID plus paracetamol formulation from the start. This strategy is supported by a 2015 Cochrane review analysing 21 over-the-counter analgesics for acute pain, which determined that more patients achieved pain relief success (defined as at least 50% maximum pain relief over 6 hours) with ibuprofen 200 mg/paracetamol 500 mg than those taking NSAID monotherapy with ibuprofen 400 mg (Figure 1).⁷

Figure 1 – Success rates for at least 50% maximum pain relief

Adapted from Appendix 4, Moore et al 2015⁷

Follow-up

Finally, long-term follow-up of patients with hand OA is recommended, and pharmacists can play an important role here. Adequate follow-up provides an opportunity for re-evaluation and adjustment of pharmacological treatments, while also helping to increase patient adherence to non-pharmacological therapies and ensure they are on the best route to recovery.² The spectrum of patients seen with hand OA is diverse, and the need for long-term follow-up should be adapted to their individual needs, taking into account severity of symptoms, presence of erosive disease, and the patient’s wishes and expectations.²

Key points

• Hand OA is a common phenotype of OA mainly affecting women, characterised by pain and functional limitation in the hands and reduced quality of life.¹
• Management should aim to control symptoms with a strong focus on patient education, individualisation, shared decision-making and a multimodal approach.²
• Topical NSAIDs can be used as initial pharmacotherapy in combination with assistive devices.²
• Oral NSAIDs are recommended when initial therapies are inadequate, with studies demonstrating improvement in pain and function; the efficacy of paracetamol is uncertain.² 

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Article references

1. Australian Institute of Health and Welfare. Osteoarthritis snapshot, what is osteoarthritis? – Australian Institute of Health and Welfare [Internet]. Australian Institute of Health and Welfare. 2018. Available from: www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/osteoarthritis/contents/what-is-osteoarthritis
2. Kloppenburg M, Kroon FP, Blanco FJ, et al. 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Annals of the Rheumatic Diseases [Internet]. 2019 Jan;78(1):16–24.
3. Kloppenburg M, Kroon F. Management of hand osteoarthritis. In: Hunter D, Curtis MR [Ed.]. UpToDate [Internet]. Available from: www.uptodate.com/contents/management-of-hand-osteoarthritis
4. Leung GJ, Rainsford KD, Kean WF. Osteoarthritis of the hand I: aetiology and pathogenesis, risk factors, investigation and diagnosis. Journal of Pharmacy and Pharmacology. 2013 Dec 13;66(3):339–46.
5. Wang X, Hunter D, Xu J, et al. Metabolic triggered inflammation in osteoarthritis. Osteoarthritis and Cartilage [Internet]. 2015 Jan;23(1):22–30.
6. Doherty M, et al. Clinical manifestations and diagnosis of osteoarthritis. In: Hunter D, Curtis MR [Ed.]. UpToDate [Internet]. Available from: www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-osteoarthritis
7. Moore RA, Wiffen PJ, Derry S, et al. Non-prescription (OTC) oral analgesics for acute pain – an overview of Cochrane reviews. The Cochrane Database of Systematic Reviews [Internet]. 2015 Nov 4 [cited 2020 Nov 25];(11):CD010794.
8. Moore N, Pollack C, Butkerait P. Adverse drug reactions and drug-drug interactions with over-the-counter NSAIDs. Therapeutics and Clinical Risk Management. 2015 Jul 15;11:1061–75.
9. Malmstrom K, Daniels S, Kotey P, et al. Comparison of rofecoxib and celecoxib, two cyclooxygenase-2 inhibitors, in postoperative dental pain: A randomized, placebo- and active-comparator-controlled clinical trial. Clinical Therapeutics. 1999 Oct;21(10):1653–63.
10. Malmstrom K, Sapre A, Couglin H, et al. Etoricoxib in acute pain associated with dental surgery: A randomized, double-blind, placebo- and active comparator-controlled dose-ranging study. Clinical Therapeutics. 2004 May;26(5):667–79.
11. Mehlisch DR, Aspley S, Daniels SE, et al. A single-tablet fixed-dose combination of racemic ibuprofen/paracetamol in the management of moderate to severe postoperative dental pain in adult and adolescent patients: A multicenter, two-stage, randomized, double-blind, parallel-group, placebo-controlled, factorial study. Clinical Therapeutics. 2010 Jun;32(6):1033–49.
12. Moore N, Vanganse E, Leparc J-M, et al. The PAIN Study: Paracetamol, Aspirin and Ibuprofen New Tolerability Study. Clinical Drug Investigation. 1999;18(2):89–98.
13. Rampal P, Moore N, Van Ganse E, et al. Gastrointestinal Tolerability of Ibuprofen Compared with Paracetamol and Aspirin at Over-the-Counter Doses. Journal of International Medical Research. 2002 Jun;30(3):301–08.
14. Varrassi G, Pergolizzi JV, Dowling P, et al. Ibuprofen Safety at the Golden Anniversary: Are all NSAIDs the Same? A Narrative Review. Advances in Therapy. 2019 Nov 8;37(1):61–82.

Author: DR CAT PANWAR BSc(Hons), PhD has over 13 years of experience in health communications across a wide range of therapeutic areas. She has represented strategically and scientifically renowned healthcare agencies across the globe. Conflict of interest: Dr Panwar is a paid consultant for Reckitt Benckiser.

Video speaker: JOHN BELL AM BPharm, FPS, FRPharmS, FACPP, MSHP, FFIP, FCPA is a practitioner/teacher at the Graduate School of Health, University of Technology Sydney, and has a community pharmacy practice. Conflict of interest: Mr Bell has been a member of advisory boards for, or provided advice to: Astellas, Astra Zeneca, Bayer, GSK, Mylan, Novartis, Nutricia, Pfizer, Procter & Gamble and Reckitt Benckiser. He is currently a member of the international multidisciplinary Global Pain Faculty.