A large meta-analysis calls hand osteoarthritis treatment guidelines into question.
Oral glucocorticoids and oral NSAIDs are effective pharmacological treatments for hand osteoarthritis, according to a large meta-analysis.
The analysis set out to explore the comparative effectiveness of pharmacological interventions for hand OA pain. Secondary objectives included function, patient global assessment, grip strength and health-related quality of life.
“Many pharmacological treatments for hand OA pain are available, of which most have no proven efficacy. For hand OA, oral NSAIDs and oral glucocorticoids appear effective, whereas the efficacy of topical NSAIDs remains questionable,” wrote the authors in RMD Open.
The findings supported previous meta-analyses that reported oral glucocorticoids and oral NSAIDs to be effective, with the authors noting that data in the current analysis favoured oral glucocorticoids over oral NSAIDs.
There was also some suggestion of efficacy for galactosaminoglycuronglycan sulfate, salicylate injections, prolotherapy, perineural glucocorticoids, antiepileptics and bisphosphonate. However, data came from only one or two trials for each intervention, and they were at high risk of bias.
Treatments not found to be effective included intra-articular hyaluronate, intra-articular glucocorticoids and hydroxychloroquine, while the effectiveness of topical NSAIDs remains uncertain.
“The lack of efficacy of intra-articular glucocorticoids echoes previous meta-analyses, but conflicts with guidelines: the ACR/Arthritis Foundation guideline for managing hand OA conditionally recommends intra-articular glucocorticoids, and EULAR guidelines state that intra-articular glucocorticoids can be considered in people with painful interphalangeal hand OA,” wrote the authors.
“These findings raise questions about the evidence supporting the current treatment recommendation for intra-articular therapies and emphasise the need for future large-scale trials with a rigorous methodology to establish the efficacy of promising interventions such as topical NSAIDs.”
The meta-analysis, carried out by an international team led by Dr Anna Døssing of the Bispebjerg and Frederiksberg Hospital in Copenhagen, included 72 trials with over 7000 patients, spanning almost 40 years from 1983 to 2021.
The authors performed several different analyses, including network meta-analysis, pairwise meta-analysis and pairwise meta-analysis excluding trials at high risk of bias.
For some interventions, the effect estimates differed among the different analyses, but oral glucocorticoids were consistently effective across all analyses for pain and were effective in function, patient global assessment and health-related quality of life, the authors noted.
For oral NSAIDs, on the other hand, there was support for consistent effectiveness in the pairwise meta-analyses on pain, function, patient global assessment and grip strength, and effectiveness in the pairwise meta-analysis without high risk of bias trials on pain, but not in the network analysis. However, the authors said, “we believe oral NSAIDs have an actual effect on pain”.
Limitations included poor reporting in some of the trials, which led to a further 40 trials being excluded from the analysis; a high risk of bias in many studies; small numbers of participants in some studies; and heterogeneity of OA types and treatment doses and routes of administration.
“Clinically, a treating physician can use our findings to avoid harm by deselecting ineffective and potentially harmful interventions such as hydroxychloroquine and intra-articular glucocorticoids for the thumb,” the authors wrote.
“To select the proper intervention for the patient, the treating physician must address comparability to the participants included in the meta-analyses, that is, Caucasian 62-year-old females. Thus, results may not be directly transferred for people with erosive and inflammatory OA as these subgroups were only included in a few trials.”
