What are the treatment options for a patient with arthritis in the hands?

Treatment of Hand Arthritis

Begin with education on joint protection techniques combined with a structured daily exercise program (range-of-motion and strengthening exercises), then add topical NSAIDs or capsaicin as first-line pharmacologic therapy, reserving oral acetaminophen for inadequate response. 1, 2

Non-Pharmacological Foundation (Start Here for All Patients)

All patients with hand arthritis should receive this foundation regardless of severity:

• Educate on joint protection techniques including proper hand positioning during daily activities, avoiding repetitive gripping motions, and minimizing adverse mechanical factors that accelerate joint damage 3, 1

• Prescribe a structured daily home exercise program consisting of both range-of-motion exercises and strengthening exercises for affected hand joints, which provides larger effect sizes for pain relief (ES = 0.32) and functional improvement (ES = 0.32) compared to education alone 3, 2

• Apply heat therapy (paraffin wax or hot packs) for 15-20 minutes before exercise sessions to improve joint mobility, with 77% expert recommendation strength 3, 1, 2

• Provide assistive devices such as jar openers, tap turners, and built-up utensil handles to reduce joint stress during activities of daily living 1

Pharmacological Treatment Algorithm

First-Line: Topical Therapy

Start with topical NSAIDs (diclofenac gel or ibuprofen cream) applied 3-4 times daily to affected joints, especially for patients ≥75 years or those with mild-to-moderate pain affecting a few joints 1, 2. Topical NSAIDs provide equivalent pain relief to oral NSAIDs (ES = 0.77) without gastrointestinal risk 4.

Alternatively, use topical capsaicin 0.025-0.075% applied as a thin film 3-4 times daily, which has a number needed to treat (NNT) of 3 for moderate pain relief 1, 2, 5.

Second-Line: Oral Acetaminophen

If topical therapy fails, prescribe oral acetaminophen up to 4g/day as the oral analgesic of first choice, with 92% expert consensus and strength of recommendation of 87/100 1, 2, 4. This has superior safety profile compared to oral NSAIDs 2.

Third-Line: Oral NSAIDs (Use With Caution)

Only prescribe oral NSAIDs after topical NSAIDs and acetaminophen have failed, using the lowest effective dose for the shortest duration 1, 2, 4.

Before prescribing oral NSAIDs, perform mandatory risk stratification:

• Cardiovascular risk assessment: history of MI, stroke, heart failure, or hypertension 1
• Gastrointestinal risk assessment: prior ulcer, GI bleeding, or concurrent anticoagulation 1
• Never use COX-2 inhibitors in patients with established cardiovascular disease 1
• Reassess necessity, efficacy, and emerging risk factors every 4-8 weeks 1

Site-Specific Interventions

For Thumb Base (Trapeziometacarpal) Osteoarthritis:

• Provide thumb splints (preferably full splint covering both thumb and wrist) with NNT of 4 for functional improvement 1, 2, 4

• Consider intra-articular corticosteroid injection for painful inflammatory flares, which is particularly effective for trapeziometacarpal joint 1, 2, 4

• Refer for surgery (interposition arthroplasty, osteotomy, or arthrodesis) if severe thumb base OA persists despite conservative treatment failure after 3-6 months 1, 2

For Lateral Angulation or Flexion Deformity:

• Supply orthoses to prevent or correct deformity progression 2, 4

Treatment Modification Based on Clinical Features

Adjust treatment intensity based on:

• Number of joints affected: Fewer joints favor topical therapy; multiple joint involvement may require systemic therapy earlier 3, 4

• Presence of inflammation: Inflammatory flares warrant earlier consideration of intra-articular corticosteroid injection 2, 4

• Type of OA: Nodal, erosive, or traumatic patterns may respond differently 3

• Severity of structural change and functional impact: Severe disability warrants accelerated progression through treatment tiers 3, 4

Critical Pitfalls to Avoid

Never start oral NSAIDs without trying topical NSAIDs first, especially in patients ≥75 years, due to superior safety profile and reduced systemic exposure 1

Never prescribe oral NSAIDs without cardiovascular and gastrointestinal risk stratification, as oral NSAIDs carry relative risk of 5.36 for GI perforation/ulcer/bleed 3, 1

Never continue oral NSAIDs indefinitely without reassessment every 4-8 weeks 1

Never omit non-pharmacologic interventions even when medications are added—these form the foundation of treatment and should always be maintained 1

Never use preserved methotrexate formulations for high-dose therapy as they contain benzyl alcohol which can cause fatal "gasping syndrome" in neonates 6