What is the best treatment approach for an older patient with hand arthritis, considering their potential medical history and age?

Treatment of Hand Osteoarthritis in Older Patients

For older patients with hand osteoarthritis, initiate treatment with topical NSAIDs as first-line therapy, followed by hand orthoses for joints other than the thumb base, with intra-articular corticosteroid injections reserved for inadequate response to initial measures. 1

First-Line Pharmacologic Management

• Topical NSAIDs are the preferred initial pharmacologic treatment for hand OA due to their superior safety profile compared to systemic medications, which is particularly important in older patients with potential comorbidities 1
• Oral NSAIDs (ibuprofen or naproxen) should be used at the lowest effective dose for the shortest duration if topical treatment proves insufficient 1
• Acetaminophen (up to 4g daily) serves as an alternative oral analgesic with favorable safety for mild to moderate pain in this population 1

Non-Pharmacologic Interventions

• Orthoses (splints) are conditionally recommended for hand joints excluding the first carpometacarpal (CMC) joint, as they can reduce pain and improve function 1
• For first CMC joint (thumb base) arthritis specifically, kinesiotaping received a conditional recommendation rather than traditional orthoses 1
• Gentle range of motion exercises should be initiated once acute symptoms are controlled to prevent stiffness and maintain function 1

Advanced Interventions for Inadequate Response

• Intra-articular corticosteroid injections are conditionally recommended specifically for hand OA when topical and oral medications provide insufficient relief 1
• Chondroitin sulfate received a conditional recommendation for hand OA in the ACR guidelines 1
• Duloxetine and tramadol are conditionally recommended options for patients requiring additional pain control, though these carry higher risks in older adults 1

Treatment Algorithm Approach

Step 1: Begin with topical NSAIDs applied to affected joints 1

Step 2: Add hand orthoses (avoiding traditional splints for thumb base arthritis) 1

Step 3: If inadequate response, advance to oral NSAIDs at lowest effective dose or acetaminophen 1

Step 4: Consider intra-articular corticosteroid injections for persistent symptoms 1

Step 5: For refractory cases, duloxetine or tramadol may be added, weighing fall risk and cognitive effects in older patients 1

Critical Considerations for Older Patients

• Avoid prolonged oral NSAID use due to increased gastrointestinal bleeding risk, cardiovascular complications, and renal impairment in older adults 1
• Thermal modalities (heat or cold) received conditional recommendations and can be safely added at any treatment stage 1
• Acupuncture is conditionally recommended as an adjunctive non-pharmacologic option 1
• The 2019 ACR/Arthritis Foundation guideline emphasizes shared decision-making that accounts for patient values, preferences, and comorbidities—particularly crucial in older patients with multiple medical conditions 1

Common Pitfalls to Avoid

• Do not use traditional orthoses for first CMC joint arthritis; kinesiotaping is preferred for this specific location 1
• Avoid starting with systemic medications when topical options have not been tried, as this exposes older patients to unnecessary systemic side effects 1
• Do not limit treatment to pharmacologic options alone; the combination of topical medications with orthoses provides superior outcomes 1

Joint-Specific Patterns

• Hand OA commonly affects the distal interphalangeal (DIP), proximal interphalangeal (PIP), and first CMC joints 2
• Radiographic hand OA prevalence can reach 80% in elderly populations, though only a subset requires treatment for symptomatic disease 2
• Approximately 33% of postmenopausal women show radiographic evidence of thumb CMC arthritis, with about 20% requiring treatment for pain and disability 3