What is the best treatment approach for arthritis that starts in the first carpometacarpal (CMC) joint and progresses to involve the entire hand?

Management of Arthritis Starting from First Carpometacarpal Joint and Spreading to Whole Hand

For arthritis that begins in the first carpometacarpal (CMC) joint and progresses to involve the entire hand, a comprehensive multimodal approach combining non-pharmacological and pharmacological treatments is strongly recommended, with first-line treatment including CMC joint orthoses, joint protection education, and topical NSAIDs. 1, 2

Non-Pharmacological Interventions

Orthoses/Splints

• First CMC joint neoprene or rigid orthoses are strongly recommended for first CMC joint OA, with long-term use (at least 3 months) advocated for optimal symptom relief 1, 2
• Custom-made orthoses are preferred to ensure proper fit and improve patient compliance 1
• Orthoses for other hand joints are conditionally recommended as the disease progresses to involve additional joints 1, 2
• Studies show 76% of patients with early-stage (I-II) disease and 54% with advanced-stage (III-IV) disease experience symptom improvement with splinting 3

Exercise and Education

• Exercise regimens involving both range of motion and strengthening exercises should be considered for all patients 1, 2
• Exercises should specifically aim at improving joint mobility, muscle strength, and thumb base stability 1
• Joint protection education to minimize stress on affected joints is essential 1, 2
• Assistive devices should be provided as needed to help perform activities of daily living more comfortably 2

Thermal Modalities

• Local application of heat (e.g., paraffin wax, hot packs), especially before exercise, can provide symptomatic relief 1, 2
• Heat therapy has stronger evidence of benefit (77% recommendation strength) compared to ultrasound (25% recommendation strength) 1

Pharmacological Interventions

Topical Treatments

• Topical treatments are preferred over systemic treatments due to safety considerations, especially for mild to moderate pain and when only a few joints are affected 1, 2
• Topical NSAIDs are the first-line pharmacological treatment for hand OA 1, 2
• Topical capsaicin may be considered as an alternative topical treatment 2

Oral Medications

• Paracetamol (acetaminophen) up to 4g/day is the oral analgesic of first choice due to its efficacy and safety profile 1
• Oral NSAIDs should be used at the lowest effective dose and for the shortest duration in patients who respond inadequately to paracetamol 1
• In persons age ≥75 years, topical rather than oral NSAIDs are recommended due to safety concerns 1, 2
• For patients with increased gastrointestinal risk, non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor should be used 1
• Tramadol may be considered for patients with inadequate response to other analgesics 2

Intra-articular Treatments

• Intra-articular injection of long-acting corticosteroid is effective for painful flares of OA, especially for the trapeziometacarpal joint 1
• However, intra-articular therapies are conditionally recommended against in the initial management of hand OA 2

Surgical Interventions

• Surgery should only be considered when other treatment modalities have not been sufficiently effective in relieving pain 2
• For severe thumb base OA, surgical options (e.g., interposition arthroplasty, osteotomy, or arthrodesis) should be considered in patients with marked pain and/or disability when conservative treatments have failed 1
• Trapeziectomy is widely considered the gold standard for advanced osteoarthritis of the first CMC joint 4
• Arthroscopic debridement and interposition arthroplasty may be viable options for treatment of moderate (Eaton stages II and III) first CMC arthritis 5

Treatment Algorithm

1. Initial Management (First-line):

   • First CMC joint orthosis/splint (custom-made if possible) 1
   • Joint protection education and exercise program 1, 2
   • Topical NSAIDs 1, 2
   • Heat therapy before exercises 1

2. If inadequate response (Second-line):

   • Add acetaminophen (up to 4g/day) 1
   • Consider assistive devices for activities of daily living 2

3. If still inadequate (Third-line):

   • Short-term oral NSAIDs at lowest effective dose 1
   • Consider intra-articular corticosteroid injection for painful flares, especially in the CMC joint 1

4. For refractory cases:

   • Consider tramadol for inadequate response to other analgesics 2
   • Evaluate for surgical intervention if marked pain/disability persists despite conservative management 1

Common Pitfalls and Caveats

• 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 should not be used in patients with hand OA 2
• Opioid analgesics are conditionally recommended against in the initial management of hand OA 2
• Splinting is most effective when used consistently for at least 3 months; shorter periods may not show significant benefit 1
• Exercise regimens for the first CMC joint differ from those for interphalangeal joints and should be tailored accordingly 1