What is the best course of action for a female patient experiencing sharp, sore pain and tingling in her left hand, who has been taking ibuprofen (Nonsteroidal Anti-Inflammatory Drug (NSAID)) and using a brace?

Management of Hand Pain and Tingling with Current Ibuprofen and Brace Use

This patient should transition from oral ibuprofen to topical NSAIDs as first-line pharmacological treatment, continue the brace if it provides symptom relief, and add structured hand exercises and education on joint protection—while limiting oral NSAID use to the shortest possible duration (7-30 days maximum) due to cardiovascular, gastrointestinal, and renal risks. 1, 2

Immediate Action: Reassess Current NSAID Use

• Oral NSAIDs should be used at the lowest effective dose for the shortest duration possible to control pain, with the American College of Rheumatology and OARSI suggesting a limit of 7-30 consecutive days, followed by periodic reevaluation. 2
• The patient has been taking ibuprofen for an unspecified duration—this needs immediate clarification, as prolonged use increases risks of gastrointestinal bleeding, cardiovascular events, and renal dysfunction. 1, 2, 3
• If the patient has been on oral ibuprofen for more than 30 days, transition to topical NSAIDs immediately unless there are specific contraindications. 1, 2

Preferred Treatment Algorithm

First-Line: Topical NSAIDs Over Oral NSAIDs

• Topical NSAIDs are preferred over systemic treatments for hand osteoarthritis because of superior safety, particularly for mild to moderate pain when only a few joints are affected. 1
• Topical NSAIDs demonstrate equivalent efficacy to oral NSAIDs for pain relief (effect size 0.77) but with significantly fewer gastrointestinal side effects (RR 0.81 vs placebo, compared to oral NSAIDs with adjusted OR 2.59 for GI bleeding). 1
• Apply topical NSAID gel to affected hand joints 3-4 times daily as the primary pharmacological intervention. 1

Continue and Optimize Brace Use

• Orthoses/splints should be considered for symptom relief in hand osteoarthritis, with long-term use advocated. 1
• For thumb base involvement specifically, full splints (covering both thumb base and wrist) provide more pain relief than half splints (effect size 0.64), with a number needed to treat of 4 for improvement in daily activities. 1
• The patient should continue the brace, particularly during activities that stress the affected joints, and consider upgrading to a full wrist-inclusive splint if thumb base is involved. 1

Add Non-Pharmacological Core Treatments

• Education and training in ergonomic principles, pacing of activity, and use of assistive devices should be offered to every patient with hand symptoms suggestive of osteoarthritis. 1
• Exercises to improve function and muscle strength, as well as to reduce pain, should be considered for every patient, including both range of motion and strengthening exercises. 1
• Local application of heat (paraffin wax, hot pack) before exercise is beneficial, though ultrasound has limited evidence. 1

If Topical NSAIDs Are Insufficient

Consider Short-Term Oral NSAIDs with Gastroprotection

• If topical treatment provides inadequate relief, oral NSAIDs may be used for a limited duration (maximum 7-30 days) at the lowest effective dose. 1, 2
• Co-prescribe a proton pump inhibitor (PPI) for gastroprotection if the patient has risk factors including age >60 years, history of GI bleeding, or concurrent aspirin use. 2, 4
• Ibuprofen should be used at the lowest effective dose (typically 400-800mg three times daily for acute flares, not to exceed 2400mg/day). 3, 5

Alternative Oral Analgesics

• Acetaminophen (up to 4g/day) is safer and more economical than NSAIDs, though its analgesic effect is lower and evidence in hand osteoarthritis specifically is limited. 1, 2
• Consider acetaminophen 1000mg three times daily as an alternative if NSAIDs are contraindicated or poorly tolerated. 1

Critical Safety Monitoring

Cardiovascular and Renal Assessment

• Evaluate cardiovascular risk factors before continuing any oral NSAID—NSAIDs are contraindicated or should be used with extreme caution in patients with significant cardiovascular disease. 2, 4
• Use NSAIDs with extreme caution or avoid them in patients with chronic kidney disease, with regular monitoring of renal function during treatment. 2, 4
• The FDA warns that NSAIDs increase risk of heart attack or stroke that can lead to death, with risk increasing with higher doses and longer duration of use. 3

Gastrointestinal Protection

• Never prescribe oral NSAIDs without gastroprotection in high-risk patients (age >60 years, history of GI bleeding, concurrent aspirin use). 2, 4
• The risk of GI bleeding increases with past history of ulcers, concomitant corticosteroids, anticoagulants, SSRIs, or SNRIs, increasing doses, longer use, smoking, and alcohol consumption. 3

Common Pitfalls to Avoid

• Do not continue oral NSAIDs indefinitely without reevaluating benefit versus risk—reassess at 7-30 days and transition to topical agents or non-pharmacological treatments. 2, 4
• Do not start or continue oral NSAIDs without first optimizing topical NSAIDs and non-pharmacological treatments unless there are specific contraindications. 2, 4
• Never combine ibuprofen with other NSAIDs, as this increases adverse event risk without additional benefit. 2, 4
• Do not underestimate the importance of exercises and joint protection education as part of comprehensive management—these are core treatments with level 1A evidence. 1

When to Consider Advanced Interventions

• Intra-articular glucocorticoid injections may be considered for painful interphalangeal joints with acute flares, though they should not generally be used in hand osteoarthritis. 1
• Surgery (trapeziectomy for thumb base OA, arthrodesis or arthroplasty for interphalangeal OA) should be considered when structural abnormalities exist and conservative treatments have failed after 3-6 months. 1

Follow-Up Timeline

• Reassess in 2-4 weeks to evaluate response to topical NSAIDs, brace use, and exercises. 1
• If no improvement after 4-6 weeks of optimized conservative therapy, consider referral to rheumatology or hand surgery for evaluation of structural abnormalities and consideration of intra-articular injections or surgical options. 1