Treatment of Hand Arthritis in Elderly Patients
Start with topical NSAIDs as first-line pharmacologic therapy for elderly patients with hand arthritis, combined with education on joint protection techniques and a daily home exercise program. 1, 2
Core Non-Pharmacological Foundation (Initiate Immediately)
Provide education on joint protection techniques to avoid mechanical factors that accelerate joint damage, including proper hand positioning during daily activities and avoiding repetitive gripping motions 1
Prescribe a structured daily home exercise program consisting of range-of-motion and strengthening exercises for affected hand joints 1
Recommend heat application (paraffin wax or hot packs) for 15-20 minutes before exercise sessions to improve joint mobility 1
Provide splints specifically for thumb base (trapeziometacarpal) osteoarthritis to reduce pain and improve function 3, 1
Supply assistive devices (jar openers, tap turners, built-up utensil handles) to help perform activities of daily living without excessive joint stress 3
Pharmacological Treatment Algorithm
Step 1: Topical Therapy (First-Line)
For patients ≥75 years, strongly prefer topical over oral NSAIDs due to superior safety profile and reduced systemic exposure 3, 2. The European League Against Rheumatism specifically recommends topical NSAIDs as first-line treatment for mild-to-moderate pain affecting a few joints 1, 2.
Topical NSAIDs (diclofenac gel, ibuprofen cream): Apply to affected joints 3-4 times daily 3, 1
Topical capsaicin 0.025-0.075%: Apply thin film 3-4 times daily with NNT of 3 for moderate pain relief; warn patients about initial burning sensation that typically diminishes after 1-2 weeks 1, 4, 5
Step 2: Oral Analgesics (If Topical Therapy Insufficient)
- Acetaminophen up to 4g/day (divided into regular doses, not just as-needed) is the oral analgesic of first choice with 92% expert consensus 1, 2
Step 3: Oral NSAIDs (Reserve for Inadequate Response)
Only prescribe oral NSAIDs after topical NSAIDs and acetaminophen have failed, and mandatory cardiovascular and gastrointestinal risk stratification must be completed first 2.
For patients with increased GI risk: Use non-selective NSAID plus proton pump inhibitor OR selective COX-2 inhibitor 3, 2
For patients with increased cardiovascular risk: COX-2 inhibitors are contraindicated; use non-selective NSAIDs with extreme caution at lowest effective dose 2
Use lowest effective dose for shortest duration with periodic reassessment every 4-8 weeks 3, 2
Step 4: Tramadol (For Refractory Pain)
- Tramadol can be added if NSAIDs are contraindicated or insufficient, though conditional recommendation only 3
What NOT to Use
Do NOT use intra-articular therapies for hand joints (conditional recommendation against) 3
Do NOT use opioid analgesics beyond tramadol (conditional recommendation against) 3
Do NOT use glucosamine or chondroitin (insufficient evidence) 3
Invasive Interventions for Severe Cases
Intra-articular corticosteroid injection is effective specifically for trapeziometacarpal (thumb base) joint during painful inflammatory flares 1
Surgical referral (interposition arthroplasty, osteotomy, or arthrodesis) should be considered for severe thumb base OA with conservative treatment failure after 3-6 months 1
Critical Pitfalls to Avoid in Elderly Patients
Never start oral NSAIDs without trying topical NSAIDs first, especially in patients ≥75 years 3, 2
Never prescribe oral NSAIDs without assessing cardiovascular risk (history of MI, stroke, heart failure, hypertension) and gastrointestinal risk (prior ulcer, GI bleeding, concurrent anticoagulation) 3, 2
Never continue oral NSAIDs indefinitely—reassess necessity, efficacy, and emerging risk factors every 4-8 weeks 2
Never use COX-2 inhibitors in patients with established cardiovascular disease 2, 6
Do not overlook the importance of non-pharmacologic interventions—these form the foundation and should never be omitted even when medications are added 3, 1