What is the recommended treatment for a patient with erosive osteoarthritis?

Erosive Osteoarthritis Treatment

For erosive osteoarthritis of the hand, do NOT use hydroxychloroquine or methotrexate—well-designed randomized controlled trials have demonstrated no efficacy for these agents despite their use in inflammatory arthritis. 1

Core Treatment Foundation

Start with non-pharmacological interventions as the foundation for all patients with erosive hand OA:

• Exercise therapy is strongly recommended and should include hand strengthening exercises, range of motion activities, and functional training, though the evidence base is less robust for hand OA compared to knee/hip OA 1
• Occupational therapy referral for instruction in joint protection techniques, splinting/orthosis fitting (particularly for first CMC joint), and adaptive equipment 1
• Weight loss if overweight or obese reduces systemic inflammatory burden even for hand OA 2

Pharmacological Treatment Algorithm

First-Line: Simple Analgesics

• Acetaminophen (paracetamol) up to 4,000 mg/day in divided doses is the safest initial oral analgesic and should be tried first 1, 2
• Topical NSAIDs applied 3-4 times daily to affected hand joints provide localized pain relief with minimal systemic absorption and are preferred over oral NSAIDs 1, 2

Second-Line: Oral NSAIDs

• Oral NSAIDs at the lowest effective dose for the shortest duration should be reserved for patients unresponsive to acetaminophen and topical NSAIDs 1
• Consider individual risk factors including age, cardiovascular disease, renal function, and gastrointestinal history when selecting an NSAID 1, 2
• Add proton pump inhibitor for gastroprotection in patients requiring oral NSAIDs, particularly those over 65 years or with GI risk factors 1

Third-Line: Intra-articular Injections

• Intra-articular corticosteroid injections may provide temporary relief for acute flares in specific joints, though evidence is limited for hand OA 1, 2

Treatments Specifically NOT Recommended for Erosive Hand OA

Critical: The following have been studied specifically in erosive hand OA and shown to be ineffective:

• Hydroxychloroquine is strongly recommended against—RCTs in erosive hand OA patients demonstrated no efficacy 1
• Methotrexate is strongly recommended against—RCTs in erosive hand OA patients demonstrated no efficacy 1
• Glucosamine is strongly recommended against for hand OA—lacks efficacy despite widespread patient use 1

One exception: Chondroitin sulfate is conditionally recommended for hand OA based on a single trial showing analgesic benefit without harm, though it is strongly recommended against for knee/hip OA 1

Common Pitfalls to Avoid

• Do not treat erosive hand OA like rheumatoid arthritis—despite the inflammatory appearance and erosions on imaging, disease-modifying antirheumatic drugs (DMARDs) like methotrexate and hydroxychloroquine have proven ineffective 1
• Do not prescribe glucosamine despite patient requests—patients often perceive efficacy due to placebo effects, but high-quality evidence shows no benefit 1
• Do not use hyaluronic acid injections in first CMC joint—conditionally recommended against due to lack of benefit in low-bias trials 1

Surgical Referral Considerations

• Refer to hand surgery when pain and functional limitation substantially affect quality of life despite 3-6 months of comprehensive conservative treatment 1, 2
• Surgical options may include joint fusion or arthroplasty for severely affected joints, particularly the first CMC joint 1