What is the best treatment approach for a patient with arthritis in their hands?

Hand Arthritis Treatment

Start with topical NSAIDs as first-line pharmacological treatment combined with hand therapy exercises, joint protection education, and thumb splinting—this approach maximizes pain relief while minimizing systemic medication risks. 1, 2

Immediate Non-Pharmacological Foundation (Start These First)

• Refer to hand therapy immediately for supervised exercise programs focusing on range-of-motion and strengthening exercises performed daily at home. 3, 1

• Provide education on joint protection techniques including proper hand positioning during daily activities, avoiding repetitive gripping motions, and pacing activities to prevent fatigue and accelerate joint damage. 1, 2, 4

• Apply heat therapy (paraffin wax or hot packs) for 15-20 minutes before exercise sessions to improve joint mobility and reduce stiffness. 1, 2

• Prescribe thumb base splints specifically for trapeziometacarpal joint involvement, as this provides significant pain reduction and functional improvement. 1, 2, 4

• Supply assistive devices such as jar openers, tap turners, and built-up utensil handles to reduce joint stress during activities of daily living. 3, 2, 4

Pharmacological Treatment Algorithm (Stepwise Progression)

Step 1: Topical Therapy (First-Line)

• Apply topical NSAIDs (diclofenac gel or ibuprofen cream) 3-4 times daily to affected joints as the initial pharmacological intervention due to superior safety profile and reduced systemic exposure. 1, 2, 4

• Consider topical capsaicin 0.025-0.075% applied as a thin film 3-4 times daily if topical NSAIDs provide insufficient relief—this has a number needed to treat (NNT) of 3 for moderate pain relief. 1, 2

Step 2: Oral Analgesics (Second-Line)

• Prescribe acetaminophen up to 4g/day as the oral analgesic of first choice if topical treatments fail, with 92% expert consensus supporting this approach. 1, 2

Step 3: Oral NSAIDs (Third-Line, Use Cautiously)

• Only prescribe oral NSAIDs after topical NSAIDs and acetaminophen have failed, using the lowest effective dose for the shortest duration with mandatory cardiovascular and gastrointestinal risk stratification. 1, 2, 5

• Reassess necessity, efficacy, and emerging risk factors every 4-8 weeks—never continue oral NSAIDs indefinitely without periodic re-evaluation. 2

• Never use COX-2 inhibitors in patients with established cardiovascular disease (history of MI, stroke, heart failure, or hypertension). 2

Invasive Interventions (For Refractory Cases)

• Administer intra-articular corticosteroid injection specifically for trapeziometacarpal (thumb base) joint during painful inflammatory flares, as this is the most responsive site for injection therapy. 1, 2, 4

• Refer for surgical consultation (interposition arthroplasty, osteotomy, or arthrodesis) after 3-6 months of failed conservative treatment in patients with severe thumb base osteoarthritis and marked pain or disability. 1, 2, 4

Critical Pitfalls to Avoid

• Never start oral NSAIDs without trying topical NSAIDs first, especially in patients ≥75 years, as this exposes patients to unnecessary systemic risks when topical therapy may suffice. 2

• Never prescribe oral NSAIDs without assessing cardiovascular risk (prior MI, stroke, heart failure, hypertension) and gastrointestinal risk (prior ulcer, GI bleeding, concurrent anticoagulation). 2

• Never omit non-pharmacological interventions even when medications are added—these form the treatment foundation and should continue throughout the disease course. 2, 4

• Never fail to provide thumb splinting for trapeziometacarpal joint involvement, as this misses an opportunity for significant symptom relief without medication. 4

Treatment Individualization Factors

• Adjust treatment intensity based on joint localization (interphalangeal joints respond differently than thumb base), type of arthritis (inflammatory vs. osteoarthritis), presence of active inflammation, and patient comorbidities. 1

• For patients currently employed or desiring employment, provide vocational rehabilitation and worksite evaluations/modifications to maintain work capacity. 3

• Provide orthoses to prevent or correct lateral angulation and flexion deformity in patients developing joint malalignment. 1