What is the treatment plan for erosive osteoarthritis (OA)?

Treatment Plan for Erosive Osteoarthritis

For erosive osteoarthritis (OA), the treatment plan should follow a comprehensive multimodal approach including physical interventions, topical and oral medications, with tumor necrosis factor inhibitors and interleukin-1 receptor antagonists strongly recommended against due to lack of efficacy and known toxicity risks. 1

Core Treatment Components

Non-pharmacological Interventions

• Exercise Program: Strong recommendation for regular, ongoing exercise tailored to patient preferences and accessibility 1

  • Focus on strengthening exercises for affected joints
  • Consider supervised programs to enhance effectiveness

• Self-efficacy and Self-management Programs: Strong recommendation 1

  • Patient education about the nature of erosive OA
  • Setting realistic expectations about disease course
  • Teaching coping strategies for pain management

• Orthoses for Hand OA:

  • Strong recommendation for first carpometacarpal (CMC) joint orthoses 1
  • Conditional recommendation for orthoses for other hand joints 1

• Thermal Modalities: Conditional recommendation for local application of heat or cold 1, 2

Pharmacological Management

1. First-line:

   • Topical NSAIDs: Strong recommendation for hand OA 1
     • Lower systemic absorption and fewer adverse effects
     • Preferred in patients ≥75 years or with GI risk factors

2. Second-line:

   • Oral NSAIDs: Strong recommendation when topical treatments are insufficient 1
     • Use minimum effective dose for shortest possible time
     • Consider naproxen with proton pump inhibitors for gastric protection 3
     • Monitor for GI, cardiovascular, and renal adverse effects

3. For moderate to severe pain:

   • Acetaminophen: Up to 4g/day for mild to moderate pain 2
   • Intraarticular glucocorticoid injections: Conditional recommendation for hand OA 1
     • Provides short-term relief (4-8 weeks)
     • Can be repeated at defined intervals

What to Avoid

• Tumor necrosis factor inhibitors and interleukin-1 receptor antagonists: Strongly recommended against in erosive hand OA 1

  • Clinical trials have demonstrated lack of efficacy
  • Known risks of toxicity outweigh potential benefits

• Platelet-rich plasma treatment: Strongly recommended against (for knee/hip OA, not evaluated in hand OA) 1

  • Concerns about heterogeneity and lack of standardization in preparations

• Stem cell injections: Strongly recommended against (for knee/hip OA, not evaluated in hand OA) 1

  • Concerns about heterogeneity and lack of standardization in preparations

Treatment Algorithm

1. Initial approach:

   • Start with first CMC joint orthoses and thermal therapies
   • Implement regular exercise program
   • Begin self-management education
   • Use topical NSAIDs for pain control

2. If inadequate response:

   • Add oral NSAIDs with gastric protection
   • Consider acetaminophen up to 4g/day

3. For refractory pain:

   • Consider intraarticular glucocorticoid injections
   • Reassess treatment plan and adherence

Important Considerations

• Assess patient for comorbidities (hypertension, cardiovascular disease, GI bleeding risk, chronic kidney disease) before finalizing treatment plan 1
• Begin pharmacological management with treatments having least systemic exposure or toxicity 1
• Address mood disorders, sleep issues, and chronic pain that may accompany erosive OA 1
• Maintain regular physical activity to prevent relapses 2

Monitoring and Follow-up

• Regular assessment of pain control and function
• Monitor for medication side effects, particularly with NSAIDs
• Adjust treatment plan based on disease progression and response to therapy

The management of erosive OA requires a stepped approach with careful consideration of benefits and risks of each intervention, particularly in patients with comorbidities or advanced age.