QD 85 - Hope For Hand OA Save
QD Clinic - Lessons from the clinic
Review of the HOPE study - Prednisolone in Hand OA
Features Dr. Jack Cush
YouTube: https://youtu.be/rM3Ta3ARURY
Transcription
Welcome to QD Clinic brought to you by RheumNow Live twenty twenty starting next week in Fort Worth. Register now. You can register now for the online access or to attend the meeting. Be sure which button you click on when you do register. This edition of QD Clinic is called Hope for Hand OA.
It's based on a journal club I attended this morning at UT Southwestern where we had a great presentation by one of our residents about the HOPE study, that's the H O P E. This is the hand osteoarthritis study wherein patients were treated either with placebo or ten milligrams of prednisolone. This is a study that's trying to answer the question, what can you do in patients with hand OA, or if you like patients with inflammatory OA of the hand, or even worse, erosive OA of the hand. In this particular study, they studied one hundred and forty nine patients and I think that they randomized most of those patients to either placebo or prednisolone, ten milligrams per day, for six weeks. After that, they tapered steroids and then withdrew them to see what would happen and reassessed them at week fourteen.
To get into the study, had to have hand OA, you had to have a swollen DIP or two, you had to have an abnormal ultrasound in many and seventy four percent had erosive changes. Moreover, if you were taking an analgesic or non steroidal, had to stop it and you had to have a spike in your pain from 30 to over 50. Well, turns out that was the case for many, but they had to modify that to over 40. So pretty stringent criteria to get in. Nonetheless, at the end of the, treatment period, the blinded treatment period, those that were treated with prednisolone did better as far as single pain visual analog scale.
I guess I should tell you first that going in, these people weren't simple in that they had an average of seven tender joints, an average of I think 4.3 swollen joints. This is not the kind of RA or OA of the hand I usually see, and clearly tenderness did improve by visual analog scale. They also, the patients did improve by OMRAC definition of response in hand OA, and they did improve somewhat, a little bit, but significant as far as powered Doppler ultrasound measurement of synovitis, but that quickly went away when the drugs was withdrawn. MRI studies did not show a difference in either bone marrow edema, a significant difference in bone marrow edema or synovitis between the two groups. So, yes, did improve and I think that that was laudable and expected.
You know, you can treat everybody with steroids and they all get better. Turns out the people who are on steroids knew they were on steroids, people were on placebo knew they were on placebo when they guessed, with almost like 90 plus percent accuracy, so you can't really hide steroid effects not from the patient. And again while this worked, the worrisome thing was that there were no significant changes on imaging really, and that the benefits were short lived, meaning as soon as you withdrew the therapy there was no sustained responses by imaging or certainly by clinic. There were a few steroid related toxicities, they did not enroll patients with heart failure or diabetes, so that wasn't really a big issue. So, again, what's the takeaway?
The authors say that you should use steroids only as short term therapy, mainly in managing a flare, mainly in managing people who have short bursts for improved activity like if they're traveling or gonna play in the next ping pong tournament. So, I do think there might be a role for steroids because we ain't got much else. Analgesics work. Acetaminophen, nonsteroidals in moderate doses, turmeric, curcumin, even cherry pills have been shown to work at times. What doesn't work?
DMARDs, Plaquenil has failed a bunch of times, methotrexate has failed, IL-one inhibitors have failed, TNF inhibitors have failed. So we got to get something else. I use a little bit of steroids, as I said before, in patients with problematic hand OA. I'll use two or two point five milligrams of prednisone along with acetaminophen up to three thousand, four thousand milligrams a day. Then I'll intermittently splint the problematic finger and joints with two inch cohesive tape for ten to fourteen days at a time.
But I think if you're going to use steroids, one, use it short term if you can. Two, never use steroids unless you tell the patient about all the toxicities. You're going to get fat, diabetic, hypertensive, stretch marks, cataracts, weak bones, fractures, common infections, pneumonias, hospitalisable infections, bizarro infections, muscle weakness, stretch marks, acne, hair thinning, can I stop now? Obviously you want to motivate the patient to either not take steroids or certainly get off the steroids if you're going to use it. So there is hope for using some steroids in some people with hand OA, it's just that it comes with a lot of warnings and certain limitations.
That's it for this week of QD Clinic.
It's based on a journal club I attended this morning at UT Southwestern where we had a great presentation by one of our residents about the HOPE study, that's the H O P E. This is the hand osteoarthritis study wherein patients were treated either with placebo or ten milligrams of prednisolone. This is a study that's trying to answer the question, what can you do in patients with hand OA, or if you like patients with inflammatory OA of the hand, or even worse, erosive OA of the hand. In this particular study, they studied one hundred and forty nine patients and I think that they randomized most of those patients to either placebo or prednisolone, ten milligrams per day, for six weeks. After that, they tapered steroids and then withdrew them to see what would happen and reassessed them at week fourteen.
To get into the study, had to have hand OA, you had to have a swollen DIP or two, you had to have an abnormal ultrasound in many and seventy four percent had erosive changes. Moreover, if you were taking an analgesic or non steroidal, had to stop it and you had to have a spike in your pain from 30 to over 50. Well, turns out that was the case for many, but they had to modify that to over 40. So pretty stringent criteria to get in. Nonetheless, at the end of the, treatment period, the blinded treatment period, those that were treated with prednisolone did better as far as single pain visual analog scale.
I guess I should tell you first that going in, these people weren't simple in that they had an average of seven tender joints, an average of I think 4.3 swollen joints. This is not the kind of RA or OA of the hand I usually see, and clearly tenderness did improve by visual analog scale. They also, the patients did improve by OMRAC definition of response in hand OA, and they did improve somewhat, a little bit, but significant as far as powered Doppler ultrasound measurement of synovitis, but that quickly went away when the drugs was withdrawn. MRI studies did not show a difference in either bone marrow edema, a significant difference in bone marrow edema or synovitis between the two groups. So, yes, did improve and I think that that was laudable and expected.
You know, you can treat everybody with steroids and they all get better. Turns out the people who are on steroids knew they were on steroids, people were on placebo knew they were on placebo when they guessed, with almost like 90 plus percent accuracy, so you can't really hide steroid effects not from the patient. And again while this worked, the worrisome thing was that there were no significant changes on imaging really, and that the benefits were short lived, meaning as soon as you withdrew the therapy there was no sustained responses by imaging or certainly by clinic. There were a few steroid related toxicities, they did not enroll patients with heart failure or diabetes, so that wasn't really a big issue. So, again, what's the takeaway?
The authors say that you should use steroids only as short term therapy, mainly in managing a flare, mainly in managing people who have short bursts for improved activity like if they're traveling or gonna play in the next ping pong tournament. So, I do think there might be a role for steroids because we ain't got much else. Analgesics work. Acetaminophen, nonsteroidals in moderate doses, turmeric, curcumin, even cherry pills have been shown to work at times. What doesn't work?
DMARDs, Plaquenil has failed a bunch of times, methotrexate has failed, IL-one inhibitors have failed, TNF inhibitors have failed. So we got to get something else. I use a little bit of steroids, as I said before, in patients with problematic hand OA. I'll use two or two point five milligrams of prednisone along with acetaminophen up to three thousand, four thousand milligrams a day. Then I'll intermittently splint the problematic finger and joints with two inch cohesive tape for ten to fourteen days at a time.
But I think if you're going to use steroids, one, use it short term if you can. Two, never use steroids unless you tell the patient about all the toxicities. You're going to get fat, diabetic, hypertensive, stretch marks, cataracts, weak bones, fractures, common infections, pneumonias, hospitalisable infections, bizarro infections, muscle weakness, stretch marks, acne, hair thinning, can I stop now? Obviously you want to motivate the patient to either not take steroids or certainly get off the steroids if you're going to use it. So there is hope for using some steroids in some people with hand OA, it's just that it comes with a lot of warnings and certain limitations.
That's it for this week of QD Clinic.
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