What is the recommended management for osteoarthritis (OA) of the hand in a geriatric female?

Management of Hand Osteoarthritis in a Geriatric Female

Begin with education on joint protection techniques combined with a structured exercise program including both range-of-motion and strengthening exercises, as this combination has demonstrated significant clinical benefit with a number needed to treat of only 2 for functional improvement. 1

Non-Pharmacological Management (First-Line Foundation)

Education and Exercise Program

• Joint protection education should focus on avoiding adverse mechanical factors during daily activities, such as using adaptive equipment for jar opening, avoiding prolonged gripping, and modifying hand positions during tasks. 1
• Range-of-motion exercises should be performed daily to maintain joint mobility and prevent contractures. 1
• Strengthening exercises targeting intrinsic and extrinsic hand muscles improve grip strength and functional capacity, though direct evidence for hand OA is limited. 1
• Exercise provides a moderate effect size of 0.32 for both pain relief and functional improvement across OA sites. 1

Self-Management Programs

• Enroll the patient in a self-efficacy and self-management program, which is strongly recommended by the American College of Rheumatology for hand OA. 1
• These multidisciplinary programs should include goal-setting, problem-solving strategies, education about medications, and joint protection measures, typically meeting 2-6 times weekly. 1

Thermal Modalities

• Local heat application (paraffin wax baths or hot packs) before exercise sessions can facilitate movement, with a strength of recommendation of 77% specifically for heat therapy. 1
• Ultrasound has weak evidence (strength of recommendation only 25%) and should not be prioritized. 1

Splinting

• For thumb base (carpometacarpal) OA specifically, provide a custom thumb splint for nighttime use, as one high-quality trial demonstrated large positive effects on pain, function, strength, and range of motion over 12 months. 1, 2
• Splints for preventing or correcting lateral angulation and flexion deformities at other joints have moderate support (strength of recommendation 67%). 1

Pharmacological Management (Stepwise Approach)

First-Line: Topical Agents

• Topical NSAIDs are the preferred initial pharmacological treatment for mild-to-moderate pain, especially when only a few joints are affected, with an effect size of 0.40 and NNT of 3. 1
• Topical capsaicin is effective with an NNT of 3 for pain relief and can desensitize nerve endings, making it particularly useful for burning sensations. 1, 3
• Topical treatments minimize systemic exposure and gastrointestinal risk compared to oral agents. 1

Second-Line: Oral Analgesics

• Acetaminophen (paracetamol) up to 4 grams daily is the oral analgesic of first choice if topical treatments are insufficient, with a strength of recommendation of 87%. 1, 4, 5, 6
• This is the preferred long-term oral option due to its safety profile in geriatric patients. 1, 5

Third-Line: Oral NSAIDs (Use With Caution)

• If acetaminophen fails, use oral NSAIDs at the lowest effective dose for the shortest duration possible, with mandatory periodic re-evaluation. 1
• In geriatric females with increased gastrointestinal risk, prescribe either a non-selective NSAID plus a proton pump inhibitor, or a selective COX-2 inhibitor. 1
• Critical caveat: COX-2 inhibitors are contraindicated in patients with cardiovascular risk factors, which are common in geriatric populations. 1
• The relative risk of GI perforation/ulcer/bleeding with NSAIDs is 5.36 in RCTs and 2.70-3.00 in observational studies. 1

Alternative Oral Agents

• Symptomatic slow-acting drugs for OA (glucosamine, chondroitin sulfate) may provide symptomatic benefit with low toxicity, but effect sizes are small (strength of recommendation 63%). 1
• These agents have not demonstrated clinically relevant structure modification or clear pharmacoeconomic benefits. 1

Invasive Treatments

Intra-Articular Corticosteroid Injections

• For painful inflammatory flares, particularly at the trapeziometacarpal (thumb base) joint, intra-articular long-acting corticosteroid injection is effective. 1
• Strength of recommendation is 60%, indicating moderate support for this intervention. 1
• One RCT showed non-significant results at 24 weeks, suggesting benefits may be temporary. 1

Surgical Considerations

When to Refer for Surgery

• Consider surgical referral (interposition arthroplasty, osteotomy, or arthrodesis) for severe thumb base OA when conservative treatments fail and symptoms substantially affect quality of life. 1, 3
• Surgery for hand OA has demonstrated effectiveness, particularly for trapeziometacarpal joint disease. 1

Critical Pitfalls to Avoid

• Do not use oral NSAIDs as first-line therapy in geriatric patients—the gastrointestinal and cardiovascular risks outweigh benefits when safer alternatives exist. 1, 6
• Avoid prolonged NSAID use without gastroprotection in elderly females, who have inherently higher GI bleeding risk. 1
• Do not overlook the importance of non-pharmacological interventions—combining modalities is more effective than monotherapy. 1
• Regular follow-up every 3-6 months is essential to reassess treatment effectiveness and adjust the management plan. 3

Weight Management Consideration

• If the patient is overweight or obese, weight loss of even 5-10% of body weight can significantly reduce joint pain and improve function, though this applies more to weight-bearing joints. 1, 3