What are the treatment options for a patient with erosive osteoarthritis of the hands?

Treatment of Erosive Osteoarthritis of the Hands

Begin with non-pharmacological interventions as the foundation of treatment, prioritizing patient education, hand orthoses (especially for thumb base involvement), exercise programs, and joint protection techniques, then add topical NSAIDs as first-line pharmacological therapy, reserving oral NSAIDs and intra-articular corticosteroids for inadequate responders. 1

Core Non-Pharmacological Interventions (First-Line for All Patients)

Patient Education and Self-Management

• Provide comprehensive education on disease nature, course, and self-management principles to every patient as a core treatment component. 1, 2 This should be an ongoing process at follow-up visits, not a one-time intervention.
• Train patients in ergonomic principles, activity pacing, and use of assistive devices to minimize joint stress. 1, 2
• Implement joint protection techniques to reduce mechanical stress on affected joints, which has demonstrated efficacy in improving pain and function. 1, 3

Orthoses and Splinting

• Prescribe custom-made neoprene or rigid orthoses for first carpometacarpal (CMC) joint involvement, with long-term use (minimum 3 months) required for optimal symptom relief. 2 Custom-made orthoses ensure proper fit and improve compliance. 2
• For interphalangeal joint involvement, consider orthoses as disease progresses to involve additional joints, though evidence is weaker than for CMC joint splinting. 2
• Common pitfall: Splinting periods shorter than 3 months may not show significant benefit—emphasize consistent long-term use. 2

Exercise Programs

• Prescribe range of motion and strengthening exercises tailored to the specific joints involved. 1, 2 Exercise regimens for CMC joints differ from those for interphalangeal joints. 2
• Focus exercises on improving joint mobility, muscle strength, and thumb base stability. 2
• Apply local heat (paraffin wax or hot packs) before exercise sessions to enhance effectiveness. 4, 2 Heat therapy has stronger evidence (77% recommendation strength) compared to ultrasound (25%). 2

Pharmacological Interventions

Topical Therapies (Preferred First-Line)

• Initiate topical NSAIDs as the first pharmacological treatment due to efficacy equal to oral NSAIDs but with fewer gastrointestinal side effects. 4, 2 Local treatments are preferred over systemic treatments, especially for mild-to-moderate pain and limited joint involvement. 4, 2
• Consider topical capsaicin as an alternative, which has a number needed to treat of 3 for clinical improvement within 4 weeks. 4

Oral Analgesics (Second-Line)

• Prescribe paracetamol (acetaminophen) up to 4g/day as the oral analgesic of first choice when topical treatments are insufficient. 2 This recommendation is based on its favorable efficacy and safety profile. 4, 2
• Add oral NSAIDs at the lowest effective dose for the shortest duration only in patients who respond inadequately to paracetamol. 2, 5
• In patients ≥75 years, strongly prefer topical over oral NSAIDs due to safety concerns. 2
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus gastroprotective agents or selective COX-2 inhibitors. 2

Intra-Articular Corticosteroids (Selective Use)

• Do not generally use intra-articular glucocorticoids in hand OA, but consider them specifically for painful interphalangeal joints with clear inflammation. 1 Recent evidence failed to confirm benefit in thumb base OA, but one trial showed efficacy for painful interphalangeal OA regarding pain during movement and joint swelling. 1
• Intra-articular corticosteroids are effective for painful flares, especially in the trapeziometacarpal joint, though evidence is mixed. 1, 2

Therapies NOT Recommended

• Do not use TNF inhibitors or IL-1 receptor antagonists—efficacy has not been demonstrated in erosive hand OA despite known toxicity risks. 1 This is a strong recommendation against use. 1
• Do not use chondroitin sulfate or other SYSADOAs—no drugs with disease-modifying properties are currently available for hand OA. 1 Results for chondroitin sulfate are inconclusive, and effect sizes for bisphosphonates are small. 1, 6
• Avoid platelet-rich plasma, stem cell injections, botulinum toxin, and prolotherapy—these lack evidence in hand OA. 1

Surgical Interventions (Last Resort)

• Consider surgery (interposition arthroplasty or arthrodesis) for severe thumb base OA with marked pain and/or disability when conservative treatments have failed. 1, 2
• For proximal interphalangeal joints, arthroplasty (typically silicone implants) is preferred, except for PIP-2 where arthrodesis may be considered. 1
• Arthrodesis is the recommended approach for distal interphalangeal joints. 1
• Ensure postoperative rehabilitation is provided. 1

Treatment Algorithm

Step 1 (All Patients):

• Custom-made CMC joint orthosis (≥3 months use) 2
• Joint protection education and exercise program 1, 2
• Topical NSAIDs 4, 2
• Heat therapy before exercises 4, 2

Step 2 (Inadequate Response):

• Add acetaminophen up to 4g/day 2

Step 3 (Persistent Symptoms):

• Short-term oral NSAIDs at lowest effective dose 2
• Consider intra-articular corticosteroid injection for painful interphalangeal joint flares 1, 2

Step 4 (Refractory Severe Disease):

• Surgical consultation for arthroplasty or arthrodesis 1, 2

Follow-Up Considerations

• Adapt long-term follow-up to individual patient needs rather than implementing routine scheduled visits. 1 Consider severity of symptoms, presence of erosive disease, need for pharmacological re-evaluation, and patient preferences. 1
• Despite erosive OA patients having more clinical and structural progression, routine follow-up does not currently add benefit in the absence of disease-modifying treatments. 1
• Follow-up can increase adherence to non-pharmacological therapies and provide opportunities for treatment revision (orthosis adjustment, pharmacological changes). 1
• Standard radiographic follow-up is not useful for most patients. 1

Critical Pitfalls to Avoid

• Do not prescribe oral NSAIDs without assessing cardiovascular, gastrointestinal, and renal risk factors, particularly in elderly patients. 7
• Do not discontinue splinting before 3 months—shorter periods show minimal benefit. 2
• Do not use combination therapy with aspirin and naproxen—aspirin increases naproxen excretion rate without demonstrated additional benefit. 5
• Do not expect disease modification from any current therapy—treatment is purely symptomatic. 1, 6 Cytokine blocking agents have not shown convincing therapeutic effect. 6