What is the recommended treatment for an adult patient with arthritis on the wrist and no significant medical history?

Recommended Treatment for Wrist Arthritis

Begin with a combined approach of education, hand exercises, and topical NSAIDs, followed by oral NSAIDs if needed, while avoiding disease-modifying drugs and reserving surgery for refractory cases with structural abnormalities. 1

Initial Non-Pharmacological Management

All patients with wrist arthritis should receive education on joint protection principles, ergonomic techniques, and pacing of activities as the foundation of treatment. 1

• Education and training in joint protection techniques should be offered to every patient with hand/wrist osteoarthritis, with strong evidence supporting this approach (Level 1b evidence, Grade A recommendation). 1
• Exercises to improve function and muscle strength while reducing pain should be considered for every patient (Level 1a evidence, Grade A recommendation). 1
• The exercise regimen should include both range of motion and strengthening exercises. 1
• For wrist involvement specifically, orthoses (splints) should be considered for symptom relief, with long-term use advocated (Level 1b evidence, Grade A recommendation). 1
• Splinting shows an effect size of 0.64 with a number needed to treat of 4 patients. 1
• Assistive devices should be provided as needed to help patients perform activities of daily living. 1
• Thermal modalities (heat or cold applications) can be used for symptom relief. 1, 2

Pharmacological Treatment Algorithm

First-Line: Topical Agents

Topical treatments are preferred over systemic treatments because of superior safety profiles, with topical NSAIDs being the first pharmacological choice. 1

• Topical NSAIDs (such as diclofenac gel) are the first pharmacological topical treatment of choice (Level 1b evidence, Grade A recommendation). 1
• Topical NSAIDs show an effect size of 0.77 for hand osteoarthritis. 1
• Topical capsaicin is an alternative topical agent that may provide pain relief, with a number needed to treat of 3 patients. 1
• In patients aged ≥75 years, topical NSAIDs should be used rather than oral NSAIDs due to safety considerations. 1

Second-Line: Oral Medications

If topical treatments fail, oral NSAIDs should be considered for limited duration at the lowest effective dose. 1

• Oral analgesics, particularly NSAIDs (including COX-2 selective inhibitors), should be considered for a limited duration for relief of symptoms (Level 1a evidence, Grade A recommendation). 1
• Oral NSAIDs show an effect size of 0.40 with a number needed to treat of 3 patients for hand osteoarthritis. 1
• Tramadol may be considered as an alternative oral analgesic. 1
• Opioid analgesics should not be used for wrist arthritis. 1

Alternative Oral Agent

• Chondroitin sulfate may be used in patients with hand osteoarthritis for pain relief and improvement in functioning (Level 1b evidence, Grade A recommendation). 1
• However, glucosamine should not be used, as high-quality evidence shows no benefit over placebo. 3

What NOT to Use

Patients with wrist/hand osteoarthritis should not be treated with conventional or biological disease-modifying antirheumatic drugs (DMARDs). 1

• This includes methotrexate, which is indicated only for rheumatoid arthritis, not osteoarthritis. 4
• Intraarticular corticosteroid injections should not generally be used in hand osteoarthritis, though they may be considered in painful interphalangeal joints (Level 1a-1b evidence, Grade A recommendation). 1
• For wrist joints specifically, intraarticular corticosteroids show no significant benefit (effect size not significant). 1

Surgical Considerations

Surgery should be considered only for patients with structural abnormalities when other treatment modalities have not been sufficiently effective in relieving pain. 1

• Surgical options for the wrist include selective excision and partial fusion, with the choice depending on the pattern of degenerative change. 5
• Modern wrist arthroplasties are not sufficiently robust to meet the demands of many patients and do not restore normal wrist kinematics. 5
• Traditional total wrist fusion eliminates movement and should be reserved for specific cases. 5

Common Pitfalls to Avoid

• Never exceed recommended NSAID doses or duration: Use the lowest effective dose for the shortest possible duration to minimize gastrointestinal, renal, and cardiovascular risks. 1
• Do not prescribe DMARDs for osteoarthritis: Methotrexate and other disease-modifying drugs are contraindicated in osteoarthritis and should only be used for inflammatory arthritis like rheumatoid arthritis. 1, 4
• Avoid relying solely on pharmacological treatment: The optimal management requires a combination of non-pharmacological and pharmacological modalities individualized to patient requirements. 1
• Do not use glucosamine or chondroitin products indiscriminately: Current high-quality evidence does not support glucosamine efficacy. 3

Treatment Individualization Factors

Treatment should be adapted based on: 1

• Localization and severity of osteoarthritis
• Presence of inflammation
• Level of pain, disability, and quality of life restriction
• Patient age (particularly for NSAID selection)
• Comorbidities and co-medications
• Patient wishes and expectations