What is the recommended NSAID (Non-Steroidal Anti-Inflammatory Drug) therapy for hand osteoarthritis?

NSAID Therapy for Hand Osteoarthritis

Oral NSAIDs should be reserved for patients who fail paracetamol (acetaminophen) and topical NSAIDs, used at the lowest effective dose for the shortest duration possible, with mandatory cardiovascular and gastrointestinal risk stratification before prescribing. 1

Treatment Algorithm for NSAID Use in Hand OA

Step 1: Topical NSAIDs as First-Line NSAID Therapy

• Topical NSAIDs are preferred over oral NSAIDs for hand OA, particularly when mild to moderate pain affects only a few joints 1
• Topical diclofenac and other topical NSAIDs provide efficacy equivalent to oral NSAIDs with significantly fewer systemic adverse events 2, 3
• Apply topical diclofenac 1% gel to affected hand joints as the initial NSAID approach 2, 4
• Topical formulations deliver therapeutic drug concentrations to joint tissues while minimizing systemic exposure and associated risks 2, 4

Step 2: Oral NSAIDs for Inadequate Response

• Prescribe oral NSAIDs only when patients respond inadequately to paracetamol (up to 4 g/day) and topical NSAIDs 1
• Use the lowest effective dose for the shortest duration necessary 1
• Re-evaluate the patient's requirements and response to treatment periodically 1

Step 3: Risk-Stratified Oral NSAID Selection

For patients with increased gastrointestinal risk:

• Prescribe non-selective NSAIDs plus a gastroprotective agent (proton pump inhibitor or H2-blocker) 1
• Alternatively, use a selective COX-2 inhibitor (coxib) 1

For patients with increased cardiovascular risk:

• COX-2 inhibitors are contraindicated 1
• Use non-selective NSAIDs with extreme caution, weighing cardiovascular risk against pain control benefits 1
• Consider the dose-dependent cardiovascular risks that increase with both NSAID dose and treatment duration 5, 3

Critical Safety Considerations

Systemic Adverse Event Profile

• Oral NSAIDs carry dose-, duration-, and age-dependent risks including gastrointestinal bleeding/ulceration, cardiovascular events (myocardial infarction, stroke), renal dysfunction, hepatotoxicity, and hematologic complications 5, 3
• Older patients and those with comorbidities face substantially higher risks from oral NSAIDs 2, 4
• Topical NSAIDs demonstrate AE profiles similar to placebo except for application site reactions, with no reported treatment-related cardiovascular or renal serious adverse events 3

Duration of Therapy

• Limit oral NSAID use to short courses (typically 7-14 days for acute flares) rather than chronic daily use 5, 3
• Topical NSAIDs may be used for longer durations given their superior safety profile 4

Common Pitfalls to Avoid

• Do not prescribe oral NSAIDs as first-line therapy when topical options have not been tried, especially in elderly patients or those with multiple comorbidities 1, 4
• Do not forget to assess cardiovascular and gastrointestinal risk factors before initiating any oral NSAID therapy 1, 5
• Do not continue oral NSAIDs indefinitely without periodic reassessment of efficacy, necessity, and emerging risk factors 1
• Do not assume all topical NSAID formulations are equivalent—diclofenac formulations have the strongest evidence for efficacy and synovial tissue accumulation 2, 4
• Do not overlook that paracetamol should be tried before any NSAID (topical or oral) given its first-line status and safety profile 1