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

Treatment for Hand Arthritis

Start with topical NSAIDs as first-line pharmacological treatment combined with thumb base splinting and joint protection education—this approach provides optimal symptom relief with the best safety profile. 1, 2

Initial Non-Pharmacological Foundation (Start Here for All Patients)

Education and Joint Protection:

• Provide education on self-management principles, disease course, and joint protection techniques to minimize mechanical stress on affected joints 2, 3
• Teach proper hand positioning during daily activities and avoidance of repetitive gripping motions 4

Orthoses/Splinting (Strongly Recommended):

• For thumb base (first CMC joint) OA: Prescribe custom-made neoprene or rigid orthoses immediately—this is a strong recommendation with high-quality evidence 2, 3
• Use splints consistently for at least 3 months for optimal benefit; shorter periods show minimal effect 2
• For other hand joints: Consider orthoses as disease progresses, though evidence is weaker 1, 2

Exercise Program:

• Prescribe daily home exercises including range-of-motion and strengthening exercises tailored to affected joints 1, 3
• Exercise regimens differ between first CMC joint and interphalangeal joints—individualize accordingly 2

Heat Therapy:

• Apply heat (paraffin wax or hot packs) for 15-20 minutes before exercise sessions to improve joint mobility 2, 4
• Heat therapy has stronger evidence (77% recommendation strength) than other physical modalities 2

Assistive Devices:

• Provide jar openers, tap turners, and built-up utensil handles to reduce joint stress during activities of daily living 4

Pharmacological Treatment Algorithm

First-Line: Topical NSAIDs

• Topical NSAIDs (diclofenac gel, ibuprofen cream) are the first pharmacological choice due to superior safety profile, especially when only a few joints are affected 1, 2, 3
• Apply 3-4 times daily to affected joints 4
• In patients ≥75 years, topical NSAIDs are strongly preferred over oral NSAIDs 1, 2, 4

Alternative Topical: Capsaicin

• Topical capsaicin 0.025-0.075% applied 3-4 times daily has NNT of 3 for moderate pain relief 3, 4

Second-Line: Oral Acetaminophen

• If topical treatments insufficient, add acetaminophen up to 4g/day—this is the oral analgesic of first choice with 92% expert consensus 2, 3, 4

Third-Line: Oral NSAIDs (Use Cautiously)

• Only prescribe oral NSAIDs after topical NSAIDs and acetaminophen have failed 4
• Use lowest effective dose for shortest duration (limited duration only) 1, 3
• Mandatory cardiovascular and gastrointestinal risk stratification before prescribing 4
• For patients with increased GI risk: Use non-selective NSAIDs plus gastroprotective agent OR selective COX-2 inhibitor 2
• Never use COX-2 inhibitors in patients with established cardiovascular disease 4
• Reassess necessity, efficacy, and emerging risk factors every 4-8 weeks—never continue indefinitely 4

Chondroitin Sulfate:

• May consider for symptom relief, though evidence is limited 1

Invasive Interventions for Refractory Cases

Intra-Articular Corticosteroid Injection:

• Effective specifically for painful inflammatory flares of the trapeziometacarpal (thumb base) joint 2, 3, 4
• Generally not recommended for interphalangeal joints 1
• Use long-acting corticosteroid formulation 2

Surgical Referral:

• Consider surgery (interposition arthroplasty, osteotomy, or arthrodesis) for severe thumb base OA with marked pain/disability when conservative treatments have failed after 3-6 months 2, 3, 4

Critical Pitfalls to Avoid

NSAID Safety:

• Never start oral NSAIDs without trying topical NSAIDs first, especially in elderly patients 4
• Never prescribe oral NSAIDs without assessing cardiovascular risk (MI history, stroke, heart failure, hypertension) and GI risk (prior ulcer, GI bleeding, concurrent anticoagulation) 4

Ineffective Therapies to Avoid:

• Do NOT use conventional or biological disease-modifying antirheumatic drugs (DMARDs)—these are discouraged for hand OA 1, 4
• Avoid long-term opioid analgesics 4
• Do not combine NSAIDs with aspirin—aspirin increases NSAID excretion and increases adverse event frequency 5

Treatment Foundation:

• Never omit non-pharmacological interventions even when adding medications—these form the treatment foundation 4

Follow-Up Strategy

• Reassess treatment response, adherence to non-pharmacological measures, and medication side effects regularly 1
• For oral NSAIDs: Mandatory re-evaluation every 4-8 weeks 4
• Splinting effectiveness should be assessed after 3 months of consistent use 2