What is the recommended treatment for severe degenerative arthritis and osteoarthritis in multiple joints of both hands?

Treatment for Severe Degenerative Hand Arthritis

For this patient with severe radioscaphoid, CMC, and interphalangeal joint osteoarthritis, begin immediately with rigid or neoprene first CMC joint orthoses bilaterally (worn consistently for at least 3 months), combined with topical NSAIDs, structured hand exercises, and heat therapy before exercise sessions. 1, 2

First-Line Non-Pharmacological Management

Orthotic Management:

• Strongly recommend rigid or neoprene first CMC joint orthoses for both hands given the bilateral moderate-to-severe CMC involvement 1, 2
• Custom-made orthoses are preferred over off-the-shelf options to ensure proper fit and improve compliance 2
• Orthoses must be worn consistently for at least 3 months minimum; shorter periods show minimal benefit 2
• For the interphalangeal joint involvement, consider additional digital orthoses or ring splints, though evidence is weaker (conditional recommendation) 1, 2

Exercise Program:

• Prescribe daily range-of-motion and strengthening exercises specifically targeting thumb base stability and grip strength 1, 2
• Exercise regimens for CMC joints differ from those for interphalangeal joints and must be tailored accordingly 2
• Supervised exercise programs produce superior outcomes compared to unsupervised home programs 1
• Referral to occupational therapy is essential for proper instruction in exercise technique and orthosis fitting 1

Heat Therapy:

• Apply local heat (paraffin wax or hot packs) before each exercise session for symptomatic relief 2
• Heat therapy has 77% recommendation strength versus only 25% for ultrasound 2

Joint Protection Education:

• Provide instruction in joint protection techniques to minimize stress on affected joints during activities of daily living 2
• Assess need for assistive devices to reduce joint loading during daily tasks 2

First-Line Pharmacological Management

Topical NSAIDs:

• Start with topical NSAIDs as first-line pharmacological treatment for all affected joints 1, 2
• Topical agents are strongly preferred over oral NSAIDs due to superior safety profile, especially given the polyarticular involvement 1, 2
• Topical NSAIDs are particularly appropriate when multiple joints are affected but pain is mild-to-moderate 2

Second-Line Pharmacological Management

If topical NSAIDs provide inadequate relief:

• Add acetaminophen up to 4g daily as the oral analgesic of first choice due to efficacy and safety 1, 2, 3
• Acetaminophen should be used at maximum dose before escalating to oral NSAIDs 2

Third-Line Pharmacological Management

If acetaminophen plus topical NSAIDs fail:

• Prescribe oral NSAIDs (such as naproxen 375-750mg twice daily) at the lowest effective dose for the shortest duration 1, 2, 3
• Critical caveat: If patient is ≥75 years old, avoid oral NSAIDs entirely and continue topical NSAIDs only 2
• For patients with gastrointestinal risk factors, combine non-selective NSAIDs with gastroprotective agents or use selective COX-2 inhibitors 1, 2
• For patients with cardiovascular risk, COX-2 inhibitors are contraindicated; use non-selective NSAIDs with extreme caution 1
• Naproxen causes statistically significantly less gastric bleeding than aspirin and has been studied safely for up to 6 months in older adults 3

Intra-articular Corticosteroid Injections:

• Reserve for acute painful flares, particularly targeting the CMC joints bilaterally 1, 2
• Provides short-term relief (4-8 weeks) and is especially effective for trapeziometacarpal joint involvement 1, 2, 4
• Can be repeated as needed for flare management 2

Surgical Consideration

For the severe right radioscaphoid arthritis with bone-on-bone articulation:

• Consider surgical referral (interposition arthroplasty, osteotomy, or arthrodesis) if conservative management fails after 3-6 months and the patient has marked pain and/or disability limiting activities of daily living 2, 5, 6
• Surgery should only be pursued after exhausting all conservative measures in stepwise fashion 5
• The right radioscaphoid joint with bone-on-bone contact may require earlier surgical evaluation than the CMC joints 6

Treatment Algorithm Summary

1. Immediate initiation: CMC orthoses bilaterally (≥3 months), topical NSAIDs, heat before exercise, structured hand exercises with occupational therapy referral 1, 2

2. Week 2-4 if inadequate response: Add acetaminophen up to 4g daily 2

3. Week 6-8 if still inadequate: Add short-term oral NSAIDs at lowest effective dose (avoid if age ≥75) 1, 2

4. For acute flares: Intra-articular corticosteroid injection to CMC joints 1, 2

5. After 3-6 months if refractory: Surgical consultation for radioscaphoid joint and/or CMC joints 2, 5, 6

Critical Pitfalls to Avoid

• Never use opioids, glucosamine/chondroitin, or disease-modifying antirheumatic drugs for hand osteoarthritis 1, 2
• Do not combine aspirin with NSAIDs; aspirin increases naproxen excretion and increases adverse event frequency 3
• Avoid intra-articular hyaluronic acid injections in hand joints (no evidence of benefit) 1
• Do not prescribe oral NSAIDs in patients ≥75 years; topical formulations only 2
• Ensure orthoses are worn for minimum 3 months; premature discontinuation negates benefit 2
• Do not proceed to surgery without documented failure of comprehensive conservative management 5