What are the treatment options for a patient with hand arthritis?

Treatment for Hand Arthritis

Optimal management of hand osteoarthritis requires a combination of non-pharmacological and pharmacological treatments, starting with education, joint protection, and exercises for all patients, followed by topical NSAIDs or capsaicin for localized pain, then acetaminophen up to 4g/day as first-line oral analgesic, escalating to oral NSAIDs at the lowest effective dose for the shortest duration if acetaminophen fails. 1

Initial Non-Pharmacological Foundation (For All Patients)

All patients with hand arthritis should receive:

• Education on joint protection techniques to avoid adverse mechanical factors that accelerate joint damage 1
• Structured exercise regimen including both range of motion and strengthening exercises performed daily at home 1, 2
• Heat application (paraffin wax or hot packs) before exercise sessions to improve joint mobility 1

The EULAR guidelines give these interventions a strength of recommendation of 59-77 for heat application, though the overall recommendation for education and exercise is moderate 1. Despite modest strength scores, these form the foundation because they have minimal risk and address functional decline 1.

Pharmacological Treatment Algorithm

Step 1: Topical Agents (First-Line for Mild-Moderate Pain)

For mild to moderate pain affecting only a few joints:

• Topical NSAIDs are preferred over systemic treatments due to superior safety profile 1
• Topical capsaicin is equally effective with NNT of 3 (95% CI: 2-5) for moderate pain relief 1
• Both have strength of recommendation of 75 (95% CI: 68-83) with 86% expert consensus 1

Step 2: Oral Acetaminophen (First-Line Systemic Analgesic)

If topical agents insufficient:

• Acetaminophen up to 4g/day is the oral analgesic of first choice due to efficacy and safety profile 1
• Strength of recommendation: 87 (95% CI: 78-96) with 92% expert consensus 1
• Should be the preferred long-term oral analgesic if successful 1

Step 3: Oral NSAIDs (Second-Line Systemic Treatment)

For patients who respond inadequately to acetaminophen:

• Use lowest effective dose for shortest duration with periodic re-evaluation 1, 3
• Naproxen has been demonstrated to cause statistically significantly less gastric bleeding than aspirin in controlled studies 4
• Gastrointestinal risk stratification is mandatory: 1
  • High GI risk: Non-selective NSAID + gastroprotective agent OR selective COX-2 inhibitor
  • High cardiovascular risk: COX-2 inhibitors are contraindicated; use non-selective NSAIDs with extreme caution
• Strength of recommendation: 81 (95% CI: 74-88) with 100% expert consensus 1
• NNT for oral NSAIDs is 3 (95% CI: 2-6) for moderate pain relief 1

Critical NSAID safety considerations from FDA labeling: 4

• Can cause ulcers and bleeding without warning symptoms
• Risk increases with: corticosteroid/anticoagulant use, longer duration, smoking, alcohol, older age, poor health
• Should not be used late in pregnancy
• May increase risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke

Adjunctive Interventions

Orthotic Devices

For thumb base (CMC-1) osteoarthritis specifically:

• Splints for thumb base OA are recommended with strength of recommendation 67 (95% CI: 57-77) 1
• Orthoses to prevent/correct lateral angulation and flexion deformity should be provided 1, 2

Symptomatic Slow-Acting Drugs (Weak Recommendation)

Glucosamine, chondroitin sulfate, avocado soybean unsaponifiables:

• May provide symptomatic benefit with low toxicity 1
• Effect sizes are small and suitable patients not well-defined 1
• Clinically relevant structure modification not established 1
• Strength of recommendation only 63 (95% CI: 48-76) 1

Invasive Interventions

Intra-Articular Corticosteroid Injection

For painful inflammatory flares:

• Long-acting corticosteroid injection is effective especially for trapeziometacarpal (thumb base) joint OA 1
• Strength of recommendation: 60 (95% CI: 47-74) 1
• Reserve for acute flares with clear inflammatory signs 1

Surgical Referral

For severe thumb base OA with conservative treatment failure:

• Surgery (interposition arthroplasty, osteotomy, or arthrodesis) should be considered when marked pain and/or disability persist despite conservative treatments 1
• Strength of recommendation: 68 (95% CI: 56-79) 1

Treatment Individualization Factors

While the algorithm above applies broadly, adjust based on: 1

• Localization: Thumb base OA responds better to splinting and injection; DIP/PIP involvement may need different orthotic approaches
• Type of OA: Erosive OA may have more inflammatory flares requiring corticosteroid injection
• Presence of inflammation: Visible swelling/warmth suggests inflammatory flare warranting injection consideration
• Comorbidities: Cardiovascular disease contraindicates COX-2 inhibitors; renal disease limits NSAID options; GI disease requires gastroprotection 1, 3

Common Pitfalls to Avoid

• Do not combine NSAIDs with aspirin as aspirin increases naproxen excretion and combination increases adverse event frequency without proven additional benefit 4
• Do not use NSAIDs for prolonged periods without periodic re-evaluation of need and risk-benefit ratio 1, 3
• Do not skip non-pharmacological interventions as they form the foundation with minimal risk and address functional decline that medications alone cannot 1, 5, 2
• Do not prescribe oral NSAIDs without assessing cardiovascular and gastrointestinal risk and implementing appropriate protective strategies 1, 4
• Do not rely on supplements (glucosamine/chondroitin) as primary therapy given small effect sizes and lack of structure-modifying evidence 1