Treatment of Hand Osteoarthritis
Begin with non-pharmacological interventions as first-line therapy, specifically education on joint protection, custom-made thumb splints for CMC joint involvement, and exercises, then add topical NSAIDs before progressing to oral analgesics. 1, 2
First-Line Non-Pharmacological Management
All patients must receive education and self-management training as the foundation of treatment. 1, 2
- Provide education on the nature and course of hand OA, self-management principles, and available treatment options 1, 2
- Instruct in joint protection techniques to minimize stress on affected joints and avoid adverse mechanical factors 1, 3
- Evaluate ability to perform activities of daily living and provide assistive devices as needed 1, 2
Splinting is essential for thumb base (first CMC joint) OA and should be custom-made for optimal compliance. 2, 3
- Use neoprene or rigid orthoses for first CMC joint OA with long-term use (at least 3 months) for optimal symptom relief 2
- Custom-made orthoses are preferred over prefabricated ones to ensure proper fit 2
- For other hand joints, orthoses may be considered as disease progresses but with lower strength of recommendation 2
Exercise programs should target range of motion, strengthening, and thumb base stability. 1, 2, 3
- Implement daily home exercise regimens involving both range of motion and strengthening exercises 2, 3
- Tailor exercises specifically to joint involvement—CMC joint exercises differ from interphalangeal joint exercises 2
Heat therapy provides symptomatic relief and should be applied before exercise. 2, 3
- Use local heat application (paraffin wax or hot packs) especially before exercise sessions 2, 3
- Heat therapy has stronger evidence (77% recommendation strength) compared to ultrasound (25%) 2
First-Line Pharmacological Management
Topical NSAIDs are the preferred first pharmacological treatment due to superior safety profile, especially when only a few joints are affected. 1, 2, 3
- Topical NSAIDs should be used before systemic treatments for mild to moderate pain 2, 3
- Topical capsaicin is an alternative with NNT of 3 for moderate pain relief 1, 2, 3
Second-Line Pharmacological Management
Add acetaminophen (paracetamol) up to 4g/day as the oral analgesic of first choice when topical treatments are insufficient. 2, 3
- Acetaminophen has 87-92% expert consensus as first-line oral analgesic 3
Third-Line Pharmacological Management
Use oral NSAIDs at the lowest effective dose for the shortest duration when acetaminophen provides inadequate relief. 1, 2, 3
- In patients ≥75 years old, strongly prefer topical over oral NSAIDs due to safety concerns 1, 2
- For patients with increased gastrointestinal risk, use non-selective NSAIDs plus gastroprotective agent or selective COX-2 inhibitor 2
- Tramadol may be considered for inadequate response to other analgesics 1, 2
Management of Inflammatory Flares
Intra-articular corticosteroid injection is effective for painful flares, particularly in the trapeziometacarpal joint. 2, 3
Surgical Intervention
Consider surgery (interposition arthroplasty, osteotomy, or arthrodesis) for severe thumb base OA with marked pain and/or disability when conservative treatments have failed. 2, 3
Critical Caveats and Common Pitfalls
Avoid intra-articular therapies and opioid analgesics in initial management of hand OA. 1, 2
Splinting requires consistent use for at least 3 months—shorter periods show minimal benefit. 2
Do not use conventional or biological disease-modifying antirheumatic drugs for hand OA. 2
Assess for comorbidities before finalizing treatment plan. 1
- Screen for hypertension, cardiovascular disease, heart failure, gastrointestinal bleeding risk, and chronic kidney disease that impact pharmacologic safety 1
Address broader impact on quality of life with multimodal approach rather than single medication. 1