hand osteoarthritis DMARDs

Anti-inflammatory Drug Doesn’t Help Hand OA

A new study found that hydroxychloroquine, a disease-modifying antirheumatic drug (DMARD) sometimes used to treat rheumatoid arthritis (RA) and lupus, does not reduce pain related to osteoarthritis (OA) of the hand, possibly ending the hope for an easy solution to a challenging problem.

Pain from hand OA affects an estimated 3 percent to 15 percent of adults over 60 and up to 31 percent of those over 70, making daily tasks difficult and diminishing quality of life. Increasing evidence suggests that low levels of inflammation may be an important source of pain in hand OA, at least in some people. Few medications are effective for hand OA other than traditional pain relievers, such as nonsteroidal anti-inflammatories (NSAIDs), acetaminophen and, in more intractable cases, opioids – all of which have side effects and can’t be used in certain populations. Researchers have been looking for other treatments.

Hydroxychloroquine is sometimes prescribed alone or in combination with other drugs to reduce inflammation in people with RA and other rheumatic conditions. It is well tolerated and relatively safe, and in addition to promising anecdotal reports, three small pilot studies found positive results. So researchers in England designed a randomized, double-blind, placebo-controlled trial to find out if hydroxychloroquine would reduce pain in hand OA. The results were published recently in Annals of Internal Medicine.

“Until now, there has not been a large-scale study into whether using hydroxychloroquine works,” says lead researcher Sarah Kingsbury, PhD, of the University of Leeds. “We therefore aimed to test the hypothesis that hydroxychloroquine was an effective analgesic for hand osteoarthritis.”

The study involved 248 adults from 13 different hospitals who had experienced hand OA pain at an average pain level of 7 out of 10 for about five years. Most participants were women, and their average age was 63. They were randomly assigned to receive a daily dose of either hydroxychloroquine or a placebo (sugar pill) for one year in addition to their usual pain medication. The researchers used questionnaires to measure the participants’ pain levels and quality of life. Some participants had ultrasounds to measure inflammation and joint damage at the start of the study, and most had their grip strength measured at 6 months and 12 months.

After six months, average pain scores had improved slightly, but the amount of improvement in the hydroxychloroquine group was no different from the placebo group. Even when the researchers looked at participants who could have benefitted the most – those who had inflammation at the start of the study – they didn’t find any difference in their response to hydroxychloroquine.

One limitation of the study is that it focused on adults with long-standing OA symptoms; results might have been different if participants had been more recently diagnosed, the researchers pointed out.

An accompanying editorial, published in the same issue of Annals of Internal Medicine as the study, praises the study as well done, but asks, “Did [hydroxychloroquine] fail to reduce inflammation, or did reduced inflammation not translate to pain relief?”

The editorial writers note that hydroxychloroquine is “a weak anti-inflammatory agent seldom used in contemporary practice as a solo disease-modifying therapy for rheumatoid arthritis and other inflammatory conditions.” They wonder if a more potent agent might have provided better pain relief, and urge further research to identify effective therapies.

This is the second recent study suggesting that hydroxychloroquine does not reduce hand OA pain. A smaller, shorter study published in November 2017 in Arthritis Care & Research also found no significant differences between those taking hydroxychloroquine and those taking a placebo for 24 weeks to treat the condition.

Robert Katz, MD, a rheumatologist at Rush University Medical Center in Chicago, is not surprised that hydroxychloroquine did not offer any relief for hand OA; it’s not recommended in any guidelines to treat the condition and that’s not what the drug is indicated for.

“I’m not saying, ‘People, don’t try hydroxychloroquine,’ but there is no support for using it on a regular basis,” says Dr. Katz, who was not involved in the study.

He says it’s disappointing that there are so few treatments for hand OA. “We can try to improve the pain from osteoarthritis of the hand either by anti-inflammatory medication or maybe a cortisone injection, and you might consider occupational or physical therapy to increase hand strength, but at this point, unfortunately, we don’t have a lot of other options.”

Author: Jennifer Davis

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