What is the next step in managing a 69-year-old female patient with osteoarthritis (OA) involving multiple joints in both hands?

Management of Hand Osteoarthritis in a 69-Year-Old Female

For a 69-year-old female with radiographic evidence of osteoarthritis in multiple hand joints, the next step should be a comprehensive treatment approach combining non-pharmacological interventions (education, assistive devices, exercises, and splints) with topical NSAIDs as first-line pharmacological therapy. 1

Initial Non-Pharmacological Management

Education and Self-Management

• Provide information about hand OA, its course, and management options 1
• Enroll patient in self-efficacy and self-management programs (strongly recommended) 1
• Teach joint protection techniques to minimize stress on affected joints 1
• Instruct in activity pacing to avoid overuse 2

Physical Interventions

• Evaluate ability to perform activities of daily living 1
• Provide assistive devices as needed to help with daily activities 1
• Prescribe hand exercises to improve joint mobility and grip strength 1
  • Range of motion exercises
  • Strengthening exercises
  • Individualized program based on patient's capabilities
• Provide splints for trapeziometacarpal (STT) joint OA which is present in both hands 1
• Instruct in use of thermal modalities (heat/cold) for pain relief 1, 2

Pharmacological Management

First-Line Treatment

• Topical NSAIDs (e.g., diclofenac gel) 1, 2
  • Apply to affected joints
  • Lower systemic exposure than oral medications
  • Particularly appropriate for patients ≥75 years (patient is 69, approaching this threshold) 1

Second-Line Options (if inadequate response to topical NSAIDs)

• Topical capsaicin 1, 2
• Oral acetaminophen (up to 3-4g/day) 2, 3
• Oral NSAIDs at lowest effective dose for shortest duration 1, 4
  • Consider naproxen 375-500mg twice daily 4
  • Use with caution due to potential side effects, especially in older adults
  • Short-term use (2-4 weeks) followed by reassessment

Treatments to Avoid or Use with Caution

• Intra-articular therapies are conditionally not recommended for hand OA 1
• Opioid analgesics are conditionally not recommended 1
• Tramadol may be considered only if other options fail 1, 2

Follow-Up and Monitoring

• Schedule follow-up within 4-6 weeks to assess response to initial therapy 1, 2
• Monitor for medication side effects, particularly with oral NSAIDs
• Consider referral to occupational therapy for specialized hand therapy 1
• Consider surgical consultation if symptoms persist despite optimal non-surgical management for 6-12 months 1, 2
  • Trapeziectomy may be considered for thumb base (STT) OA
  • Arthrodesis or arthroplasty may be considered for interphalangeal joint OA

Important Considerations

• Hand OA treatment should focus on maintaining function and quality of life, not just pain relief 1
• The combination of non-pharmacological and pharmacological approaches is more effective than either alone 5, 6
• Cognitive behavioral therapy may be beneficial for pain management 1
• Weight management should be addressed if the patient is overweight, as this can impact overall OA management 1, 2

This approach aligns with the most recent guidelines from the American College of Rheumatology and European League Against Rheumatism (EULAR), which emphasize the importance of non-pharmacological interventions alongside judicious use of pharmacological treatments for hand OA 1.