What treatment options does a rheumatologist recommend for hand osteoarthritis (OA)?

Rheumatologist Treatment Recommendations for Hand Osteoarthritis

For hand osteoarthritis, rheumatologists recommend a combination of nonpharmacologic interventions (including joint protection techniques, assistive devices, thermal modalities, and splints for thumb base OA) and pharmacologic treatments (primarily topical NSAIDs first, followed by oral NSAIDs when needed), with treatment selection based on patient age and comorbidities. 1, 2

Nonpharmacologic Interventions

Education and Self-Management

• All patients should receive education about the nature and course of hand OA and instruction in self-management principles 2
• Evaluation of the patient's ability to perform activities of daily living (ADLs) is essential for appropriate treatment planning 1

Joint Protection and Assistive Devices

• Joint protection techniques should be taught to minimize stress on affected joints 1, 2
• Appropriate assistive devices should be provided to help patients perform ADLs more comfortably 1, 2

Physical Interventions

• Thermal modalities (both heat and cold) are conditionally recommended for pain relief 1, 2
• Splints are strongly recommended for patients with thumb base (trapeziometacarpal joint) OA 1, 2
• Exercise programs to improve hand function and muscle strength should be considered, though evidence shows only small beneficial effects 3

Pharmacologic Interventions

First-Line Treatments

• Topical treatments are preferred over systemic treatments due to safety considerations 2
• Topical NSAIDs are the first pharmacological treatment of choice for hand OA 2
• Topical capsaicin may be considered as an alternative topical treatment 1

Second-Line Treatments

• Oral NSAIDs (including COX-2 selective inhibitors) should be considered for a limited duration when topical treatments are insufficient 1, 2
• For patients ≥75 years, topical rather than oral NSAIDs are recommended due to safety concerns 1
• Tramadol may be considered for patients with inadequate response to other analgesics 1

Treatment Algorithm Based on Age and Severity

For All Patients

1. Provide education on hand OA and self-management strategies 2
2. Evaluate ADLs and provide appropriate assistive devices 1, 2
3. Instruct in joint protection techniques 1, 2
4. Recommend thermal modalities for symptom relief 1, 2
5. Prescribe splints for thumb base OA if present 1, 2

For Initial Pharmacologic Treatment

1. Start with topical NSAIDs 2
2. If inadequate response, consider:
   • For patients <75 years: Add oral NSAIDs for limited duration 1
   • For patients ≥75 years: Continue with topical NSAIDs or try topical capsaicin 1
3. For patients with insufficient relief: Consider tramadol 1

Common Pitfalls and Caveats

• Intraarticular therapies and opioid analgesics are conditionally recommended against in the initial management of hand OA 1, 2
• Long-term use of oral NSAIDs should be avoided due to potential gastrointestinal, cardiovascular, and renal adverse effects 2
• Conventional or biological disease-modifying antirheumatic drugs (DMARDs) are not recommended for hand OA 2, 4
• There are currently no disease-modifying OA drugs (DMOADs) available for hand OA 4
• Surgery should only be considered when other treatment modalities have not been sufficiently effective in relieving pain 2
• The evidence base for hand OA treatments is less robust than for knee or hip OA, with few high-quality randomized controlled trials available 1, 5

Effectiveness of Treatments

• Nonpharmacologic interventions generally show small to moderate effect sizes for pain and function improvement 1, 3
• Exercise interventions show small beneficial effects on hand pain, function, and finger joint stiffness, but these benefits may not be sustained long-term 3
• Pharmacologic treatments primarily provide symptomatic relief rather than disease modification 4
• In clinical practice, pharmacological treatments (77%) are used more frequently than nonpharmacological treatments (47%) 5