What are the treatment options for hand osteoarthritis (OA)?

Treatment Options for Hand Osteoarthritis

The optimal management of hand osteoarthritis requires a combination of non-pharmacological and pharmacological treatments, with topical NSAIDs being the first-line pharmacological therapy due to their efficacy and safety profile. 1

Non-Pharmacological Interventions

Education and Self-Management

• Enroll patients in self-efficacy and self-management programs 2, 1
• Teach joint protection techniques to minimize stress on affected joints 2, 1
• Provide education about avoiding adverse mechanical factors 2

Exercise Therapy

• Prescribe hand exercises to improve joint mobility and grip strength 2, 1
  • Include both range of motion exercises and strengthening exercises 2
  • Exercise programs should be individualized based on patient's capabilities 1

Assistive Devices and Orthoses

• Evaluate ability to perform activities of daily living and provide assistive devices as needed 1
• Recommend splints for thumb base OA (trapeziometacarpal joint) 2, 1
  • Strong recommendation with evidence showing benefit 2
• Consider orthoses to prevent/correct lateral angulation and flexion deformity 2

Physical Modalities

• Local application of heat (e.g., paraffin wax, hot packs) before exercise 2
• Consider thermal modalities for pain relief 2

Pharmacological Interventions

Topical Treatments (First-Line)

• Topical NSAIDs are strongly recommended as first-line pharmacological therapy 2, 1
  • Lower systemic exposure than oral medications 1
  • Particularly appropriate for patients ≥75 years 1
  • FDA-approved for OA pain relief 3
• Topical capsaicin may be considered for pain relief 1, 4
  • Apply 3-4 times daily for best results 4

Oral Analgesics

• Paracetamol (acetaminophen) up to 4g/day is recommended as first oral analgesic choice 2
  • Use for mild to moderate pain 5
• Oral NSAIDs should be used at lowest effective dose for shortest duration 2, 3
  • Consider only in patients who respond inadequately to paracetamol 2
  • Use with caution due to potential side effects, especially in older adults 1
  • For moderate to severe pain 5
• In patients with increased gastrointestinal risk, use non-selective NSAIDs with gastroprotective agent or COX-2 inhibitor 2
• In patients with increased cardiovascular risk, COX-2 inhibitors are contraindicated and non-selective NSAIDs should be used with caution 2

Other Pharmacological Options

• Chondroitin sulfate may provide symptomatic benefit with low toxicity 2, 1
• Intra-articular corticosteroid injections may be considered for painful interphalangeal joint OA 2, 1
  • Generally not recommended as first-line therapy 1
• Tramadol may be considered only if other options fail 1
• Disease-modifying antirheumatic drugs are discouraged 2

Surgical Interventions

• Consider surgical consultation if symptoms persist despite optimal non-surgical management for 6-12 months 1
• Surgery (e.g., interposition arthroplasty, osteotomy, arthrodesis) is effective for severe thumb base OA when conservative treatments have failed 2

Treatment Algorithm

1. Start with non-pharmacological interventions (education, exercises, splints)
2. Add topical NSAIDs for pain relief
3. If inadequate response, consider oral paracetamol
4. If still inadequate, consider short-term oral NSAIDs at lowest effective dose
5. Consider chondroitin sulfate as adjunct therapy
6. Reserve intra-articular corticosteroids for specific painful flares
7. Consider surgical options only after failure of comprehensive non-surgical management

Follow-Up and Monitoring

• Schedule follow-up within 4-6 weeks to assess response to initial therapy 1
• Monitor for medication side effects, particularly with oral NSAIDs 1
• Consider referral to occupational therapy for specialized hand therapy 1

Common Pitfalls and Caveats

• Avoid prolonged use of oral NSAIDs due to gastrointestinal, cardiovascular, and renal risks
• Do not rely solely on pharmacological treatments; non-pharmacological approaches are essential
• Remember that no current interventions have definitively shown to slow radiographic progression 6
• Recognize that more complex surgical procedures may lead to more complications 6
• Avoid opioid analgesics as they are generally not recommended for hand OA 1