Is it okay to use Plaquenil (hydroxychloroquine) for joint swelling in the hands in a patient negative for Rheumatoid Arthritis (RA)?

Hydroxychloroquine (Plaquenil) is Not Recommended for Joint Swelling in Patients Negative for Rheumatoid Arthritis

Hydroxychloroquine (Plaquenil) is strongly recommended against for treating joint swelling in the hands in patients who are negative for rheumatoid arthritis. 1

Evidence Against Hydroxychloroquine Use in Non-RA Joint Swelling

The 2019 American College of Rheumatology/Arthritis Foundation guidelines for osteoarthritis (OA) management provide clear direction on this issue:

• Well-designed randomized controlled trials of hydroxychloroquine, specifically conducted in patients with erosive hand OA, have demonstrated no efficacy 1
• Hydroxychloroquine is strongly recommended against in patients with knee, hip, and/or hand OA 1

Recommended Treatments for Hand Joint Swelling in Non-RA Patients

For patients with hand joint swelling who are negative for RA, the following evidence-based approaches are recommended:

First-line Treatments:

1. Topical NSAIDs: Strongly recommended for hand OA as first-line pharmacologic therapy 1

   • Preferred over oral medications due to less systemic exposure
   • May require consideration of practical factors (e.g., frequent hand washing)

2. Oral NSAIDs: Strongly recommended if topical NSAIDs are insufficient 1

   • Remain the mainstay of pharmacologic management
   • Should be used at the lowest effective dose for the shortest duration

3. Non-pharmacologic approaches:

   • Orthoses for first CMC joint: Conditionally recommended 1
   • Joint protection techniques: Conditionally recommended 1
   • Exercise programs: Strongly recommended 1

Second-line Treatment:

• Chondroitin sulfate: Conditionally recommended specifically for hand OA 1
  • A single trial suggested analgesic efficacy without evidence of harm

Potential Risks of Hydroxychloroquine

While hydroxychloroquine is generally considered to have a favorable safety profile compared to other disease-modifying antirheumatic drugs (DMARDs), it still carries risks that don't justify its use when evidence shows lack of efficacy:

• Retinal toxicity risk with long-term use 2
• Gastrointestinal side effects 3
• Potential for drug interactions

Algorithm for Managing Hand Joint Swelling in Non-RA Patients

1. Confirm diagnosis: Ensure proper diagnosis of OA or other non-RA condition
2. Start with non-pharmacologic approaches:
   • Joint protection techniques
   • Hand exercises
   • First CMC joint orthoses if appropriate
3. Initial pharmacologic therapy:
   • Topical NSAIDs (first choice)
   • Oral NSAIDs if topical treatment insufficient
4. Consider second-line options:
   • Chondroitin sulfate
   • Intra-articular steroid injections (for acute flares)

Common Pitfalls to Avoid

• Using hydroxychloroquine for non-RA joint swelling: Despite its effectiveness in RA, hydroxychloroquine has been proven ineffective for OA in well-designed studies 1
• Delaying effective treatment: Starting with ineffective treatments delays symptom relief and may lead to further joint damage
• Overlooking non-pharmacologic approaches: Exercise and orthoses can provide significant benefit with minimal risk

Conclusion

The evidence clearly demonstrates that hydroxychloroquine should not be used for joint swelling in patients who test negative for RA. Instead, focus on evidence-based treatments including topical NSAIDs, oral NSAIDs, orthoses, and appropriate exercise programs to manage symptoms and maintain function.