What is the best treatment approach for an older adult patient with bilateral hand osteoarthritis (OA) and swelling, with no significant comorbidities?

Treatment for Bilateral Hand Osteoarthritis with Swelling

Start with topical NSAIDs as first-line pharmacological treatment combined with a custom-made thumb splint (if thumb base is involved), joint protection education, and a structured exercise program—this combination addresses both the inflammatory swelling and underlying joint pathology while minimizing systemic side effects. 1, 2

Initial Non-Pharmacological Management

The foundation of treatment must include non-pharmacological interventions, which should be implemented immediately:

• Custom-made orthoses/splints are strongly recommended for first carpometacarpal (CMC) joint involvement, with long-term use (at least 3 months) required for optimal symptom relief 2, 1
• Joint protection education to minimize stress on affected joints is essential for all patients 2, 1
• Exercise regimens involving both range of motion and strengthening exercises should be prescribed, specifically targeting joint mobility, muscle strength, and thumb base stability 2, 1
• Heat therapy (paraffin wax or hot packs) applied before exercises provides symptomatic relief and has stronger evidence (77% recommendation strength) compared to other modalities 2, 1

Pharmacological Treatment Algorithm

First-Line: Topical Therapy

• Topical NSAIDs are the first-choice pharmacological treatment for hand OA, preferred over systemic treatments due to superior safety profile, especially for mild-to-moderate pain when only a few joints are affected 1, 2
• Topical capsaicin may be considered as an alternative topical agent 1

Second-Line: Oral Analgesics

If topical treatments provide inadequate relief:

• Acetaminophen (paracetamol) up to 4g/day is the oral analgesic of first choice due to its efficacy and safety profile, and is the preferred long-term oral analgesic 2, 1

Third-Line: Oral NSAIDs

• Oral NSAIDs should be used at the lowest effective dose for the shortest duration in patients who respond inadequately to acetaminophen 2, 1
• In patients ≥75 years old, topical NSAIDs are strongly preferred over oral NSAIDs due to safety concerns regarding gastrointestinal, cardiovascular, and renal adverse effects 2, 1
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 2, 1

Management of Swelling and Inflammatory Flares

For patients presenting with swelling, which suggests an inflammatory component:

• Intra-articular corticosteroid injections may be considered specifically for painful interphalangeal joints with swelling, though they should not generally be used for hand OA 1
• The 2018 EULAR update revised previous recommendations after new evidence showed intra-articular glucocorticoids were not effective for thumb base OA, but one trial demonstrated efficacy for painful interphalangeal OA with joint swelling 1
• Intra-articular corticosteroids are effective for trapeziometacarpal joint flares according to older guidelines, though this has been questioned by more recent evidence 1

What NOT to Use

• Conventional or biological disease-modifying antirheumatic drugs (DMARDs) are discouraged and should not be used in hand OA 1, 2
• Opioid analgesics are conditionally recommended against in initial management 1, 2
• Chondroitin sulfate may provide symptomatic benefit but effect sizes are small and clinically relevant structure modification has not been established 1

Surgical Considerations

For severe disease refractory to conservative management:

• Surgery (interposition arthroplasty or arthrodesis) should be considered for severe thumb base OA in patients with marked pain and/or disability when conservative treatments have failed 2, 1
• Simple trapeziectomy alone is as effective as combined procedures (trapeziectomy + ligament reconstruction) but has fewer complications (tendon rupture, scar tenderness, neurological complications) 1

Common Pitfalls to Avoid

• Splinting must be used consistently for at least 3 months—shorter periods may not show significant benefit 2
• Do not continue long-term oral NSAIDs due to cumulative gastrointestinal, cardiovascular, and renal risks 2
• Exercise regimens for the first CMC joint differ from those for interphalangeal joints and must be tailored accordingly 2
• The presence of swelling may mimic rheumatoid arthritis—if clinical features are atypical, consider ultrasound imaging to differentiate OA from inflammatory arthritis, as this fundamentally changes management 3