Treatment Options for Hand Arthritis Without NSAIDs or Aspirin
For a 76-year-old man who cannot take systemic NSAIDs or aspirin, start with topical NSAIDs (diclofenac gel 3-4 times daily) combined with acetaminophen up to 4g/day, alongside daily hand exercises and heat application before activity. 1, 2
First-Line Pharmacological Treatment
Topical NSAIDs are the preferred initial pharmacological approach for hand arthritis when systemic NSAIDs are contraindicated, particularly in patients over 75 years. 1, 2 Apply diclofenac sodium 1% gel to affected joints 3-4 times daily—this delivers effective drug concentrations to the joint with minimal systemic absorption and avoids the gastrointestinal and cardiovascular risks of oral NSAIDs. 2, 3
Acetaminophen remains the oral analgesic of first choice with 92% expert consensus and should be prescribed at regular intervals up to 4g/day (not just as-needed dosing). 1, 4 This combination of topical NSAID plus scheduled acetaminophen provides synergistic pain relief while maintaining safety in elderly patients. 2, 4
Topical capsaicin 0.025-0.075% applied as a thin film 3-4 times daily offers an additional option with a number needed to treat of 3 for moderate pain relief. 1, 2 Warn the patient about initial burning sensation that typically diminishes after 1-2 weeks of consistent use. 4, 3
Essential Non-Pharmacological Foundation
These interventions form the treatment backbone and must never be omitted even when medications are added:
Prescribe a structured daily home exercise program consisting of range-of-motion exercises (making a fist, spreading fingers wide, touching each fingertip to thumb) and strengthening exercises (squeezing therapy putty) performed 10-15 repetitions twice daily. 1, 2
Apply heat for 15-20 minutes before exercise sessions using paraffin wax baths or hot packs to improve joint mobility and reduce stiffness. 1, 2
Provide thumb base splints specifically for trapeziometacarpal joint osteoarthritis to reduce pain and improve function during activities. 1, 2, 5
Supply assistive devices including jar openers, tap turners, and built-up utensil handles to perform daily activities without excessive joint stress. 1, 2
Educate on joint protection techniques such as using larger, stronger joints when possible (pushing doors open with forearm rather than hand), avoiding prolonged gripping, and taking frequent rest breaks during repetitive tasks. 1, 2, 5
Second-Line Options When First-Line Treatment Fails
Intra-articular corticosteroid injection is highly effective specifically for the trapeziometacarpal (thumb base) joint during painful inflammatory flares. 1, 2, 5 Inject 5-15mg triamcinolone acetonide using strict aseptic technique into the affected joint space. 6 This provides relief lasting weeks to months and can be repeated, though reassess necessity every 4-8 weeks. 2
Tramadol represents a useful bridging analgesic for patients with inadequate relief from acetaminophen who cannot take NSAIDs and are not yet candidates for stronger opioids. 7, 4 Start at 50mg twice daily and titrate based on response and tolerability.
Low-dose opioids may be appropriate for severe, refractory pain when other interventions prove insufficient, though this requires careful risk-benefit assessment in a 76-year-old patient regarding fall risk and cognitive effects. 7
When to Consider Surgical Referral
Refer for surgical evaluation (interposition arthroplasty, osteotomy, or arthrodesis) when severe thumb base osteoarthritis causes marked pain and disability despite 3-6 months of conservative treatment failure. 1, 2, 5 Surgery shows consistent effectiveness for restoring function in appropriately selected patients. 1
Critical Pitfalls to Avoid
Never start oral NSAIDs without first trying topical NSAIDs in patients over 75 years—the systemic exposure and adverse event risk are substantially higher with oral formulations. 2, 3
Never prescribe oral NSAIDs without cardiovascular risk assessment (history of myocardial infarction, stroke, heart failure, hypertension) and gastrointestinal risk assessment (prior ulcer, GI bleeding, concurrent anticoagulation), as COX-2 inhibitors are contraindicated in established cardiovascular disease. 1, 2
Never continue oral NSAIDs indefinitely if they become necessary—reassess necessity, efficacy, and emerging risk factors every 4-8 weeks and use the lowest effective dose for the shortest duration. 1, 2
Never overlook non-pharmacologic interventions as these form the foundation of treatment and should never be omitted even when medications are added. 1, 2, 8