What is the initial treatment for osteoarthritis (OA) of the hands?

Initial Treatment for Osteoarthritis of the Hands

The initial treatment for hand osteoarthritis should include education about the condition, joint protection techniques, exercises to improve function and muscle strength, and splints for thumb base OA, along with topical NSAIDs as the first pharmacological treatment of choice. 1

Non-pharmacological Interventions

Education and Self-Management

• All patients should be offered information on the nature and course of hand OA, as well as education on self-management principles and treatment options 1
• Self-efficacy and self-management programs are strongly recommended as they help patients understand their condition and actively participate in their care 1

Joint Protection and Assistive Devices

• Instruction in joint protection techniques should be provided to every patient to minimize stress on affected joints 1
• Evaluation of the patient's ability to perform activities of daily living (ADLs) is essential 1
• Assistive devices should be provided as needed to help patients perform ADLs more comfortably 1

Exercise Therapy

• Exercises to improve function and muscle strength, as well as to reduce pain, should be considered for every patient 1
• These exercises help maintain joint mobility and strengthen supporting muscles around affected joints 1, 2

Orthoses/Splints

• Splints are strongly recommended for patients with thumb base (trapeziometacarpal joint) OA 1
• Long-term use of orthoses is advocated for symptom relief 1
• For joints other than the first carpometacarpal joint, orthoses may be considered but with a lower level of recommendation 1

Thermal Modalities

• Patients should be instructed in the use of thermal modalities (heat and cold) for pain relief 1
• Local application of heat (e.g., paraffin wax, hot packs), especially before exercise, can provide symptomatic relief 1

Pharmacological Interventions

Topical Treatments

• Topical treatments are preferred over systemic treatments because of safety reasons 1
• Topical NSAIDs are the first pharmacological treatment of choice for hand OA 1
• Topical capsaicin may be considered as an alternative topical treatment 1, 3
  • For best results, capsaicin should be applied 3-4 times daily 3

Oral Analgesics

• Oral NSAIDs, including COX-2 selective inhibitors, should be considered for a limited duration for relief of symptoms when topical treatments are insufficient 1
• In persons age ≥75 years, topical rather than oral NSAIDs are recommended due to safety concerns 1
• Naproxen and other NSAIDs have been shown to be effective in controlling joint pain and tenderness in OA patients 4
• Acetaminophen (paracetamol) may be considered, though recent guidelines have reduced its prominence due to concerns about efficacy 5
• Tramadol may be considered for patients with inadequate response to other analgesics 1

Treatment Algorithm

1. First-line approach:

   • Patient education and self-management strategies
   • Joint protection techniques and assistive devices
   • Exercise program for hand function and strength
   • Splints for thumb base OA
   • Topical NSAIDs

2. If inadequate response:

   • Add oral NSAIDs for limited duration (with appropriate gastrointestinal protection if needed)
   • Consider topical capsaicin
   • Consider tramadol for more severe pain

3. For specific situations:

   • For older patients (≥75 years): Prioritize topical over oral NSAIDs
   • For thumb base OA: Ensure proper splinting is implemented
   • For patients with significant functional limitations: Intensify exercise program and consider occupational therapy referral

Common Pitfalls and Caveats

• Intra-articular therapies and opioid analgesics are conditionally recommended against in the initial management of hand OA 1
• Long-term use of oral NSAIDs should be avoided due to potential gastrointestinal, cardiovascular, and renal adverse effects 1, 4
• Conventional or biological disease-modifying antirheumatic drugs should not be used in patients with hand OA 1
• Surgery should only be considered when other treatment modalities have not been sufficiently effective in relieving pain 1
• No disease-modifying treatment currently exists for hand OA, so management focuses on symptom control and functional improvement 2