SR: Efficacy and Safety of Non-Pharmacological, Pharmacological, and Surgical Treatments for Hand Osteoarthritis

Background: Hand osteoarthritis (OA) affects a substantial proportion of older adults, contributing to pain, reduced grip strength, and functional limitations. While several clinical guidelines recommend patient education, exercise, and topical or oral non-steroidal anti-inflammatory drugs (NSAIDs), the level of evidence remains varied. In 2018, a systematic review identified efficacy data from 126 studies. This updated review includes 65 new randomized controlled trials (RCTs) published through December 2023, aiming to provide the most current evidence on hand OA treatments.

Objective: To summarize and evaluate the efficacy and safety of non-pharmacological, pharmacological, and surgical interventions for hand OA, highlighting both short-term (<3 months) and long-term (≥3 months) outcomes for pain, function, and grip strength.

Methods: The authors searched PubMed/MEDLINE, Embase, and Cochrane CENTRAL for RCTs published from June 2017 to December 2023. Risk of bias was assessed using the RoB2 tool, and certainty of evidence was evaluated with GRADE criteria. Interventions included hand exercises, orthoses, assistive devices, thermal modalities, pharmacologic therapies (e.g., oral/topical NSAIDs, glucocorticoids, disease-modifying anti-rheumatic drugs), and various surgical techniques. Meta-analyses were conducted when appropriate, and outcomes were expressed as standardized mean differences or relative risks with 95% confidence intervals.

Results:

• Non-Pharmacological Interventions: Low- to moderate-certainty evidence supports hand exercises, thumb orthoses, and assistive devices for improving pain and function. Hand exercises showed a small long-term effect on pain, while thumb orthoses offered a moderate long-term effect on pain. Assistive devices demonstrated a moderate long-term benefit for function. Few mild adverse events were reported in these categories.
• Pharmacological Interventions: There is high-certainty evidence for a very small short-term functional improvement with topical NSAIDs and low-certainty evidence of moderate short-term pain relief with oral NSAIDs. Oral glucocorticoids likely yield a small, short-term functional benefit. Methotrexate showed a possible small long-term effect on pain but no clear impact on function. No new data support intra-articular steroid injections, hydroxychloroquine, or biologic DMARDs for meaningful improvements; in these trials, sponsor bias and cost considerations underscore the need for critical appraisal, given the typically higher expense of advanced agents like biologics.
• Surgical Interventions: Ten new studies compared various surgical techniques but did not include robust controls versus nonsurgical management or sham surgery. Heterogeneity precluded pooling of results, and no definitive superiority emerged for any particular procedure.

Conclusions: This systematic review reaffirms the central role of non-pharmacological interventions, especially exercise, orthoses, and assistive devices, for improving pain and function in hand OA with minimal adverse events. Pharmacological treatments offer modest short-term benefits, particularly oral NSAIDs, although cost, side-effect profiles, and real-world adherence should be considered. Surgical approaches lack high-quality comparative data, highlighting the need for well-designed trials.

Implications for Practice: Clinicians should prioritize patient education, exercises, and readily accessible interventions (e.g., orthoses, assistive devices) given their demonstrated safety and moderate efficacy. Oral or topical NSAIDs remain suitable options for acute pain management, with the understanding that longer-term use warrants caution due to possible adverse effects. In contexts where advanced pharmacologic agents (such as biologics) are evaluated, practitioners must scrutinize costs, potential sponsor influence, and marginal benefits relative to standard care.

Study Strengths and Limitations: Strengths of this review include a comprehensive literature search, systematic appraisal of risk of bias, and application of GRADE to gauge certainty. However, most RCTs were small in size or had high or unclear risk of bias, and considerable heterogeneity in study designs reduced comparability. Additional limitations include the scarcity of direct comparisons for surgical versus non-surgical approaches and inconsistent reporting of adverse events.

Future Research: High-quality, larger-scale RCTs are needed to clarify subtypes of hand OA and tailor treatments accordingly. Trials should evaluate long-term outcomes, systematically measure adverse events, and compare surgery directly with non-surgical options. Studies employing mobile health (mHealth) tools and addressing ways to enhance grip strength may further advance evidence-based hand OA management.

Reference:
Kjeken I, Bordvik DH, Osteras N, Haugen IK, Fjeldstad KAA, Skaalvik I, Kloppenburg M, Kroon FPB, Tveter AT, Smedslund G. Efficacy and safety of non-pharmacological, pharmacological and surgical treatments for hand osteoarthritis in 2024: a systematic review. RMD Open. 2024; e004963. DOI: https://doi.org/10.1136/rmdopen-2024-004963