What are the recommended treatment options for hand arthritis, including both osteoarthritis and inflammatory forms such as rheumatoid arthritis?

Treatment of Hand Arthritis

Osteoarthritis of the Hand

For hand osteoarthritis, begin with topical NSAIDs as first-line pharmacological therapy combined with custom-made thumb orthoses (for CMC joint involvement), joint protection education, and structured exercise programs. 1

First-Line Non-Pharmacological Management

Orthoses and Splinting:

• Custom-made rigid or neoprene orthoses for first CMC (thumb base) joint OA must be worn continuously for at least 3 months to achieve clinical benefit; shorter durations are ineffective 2
• Custom-fabricated orthoses improve compliance compared to prefabricated devices 2
• For interphalangeal joints, orthoses may be considered but have lower evidence strength 3

Education and Self-Management:

• Provide joint protection education to minimize mechanical stress on affected joints 1, 4
• Teach ergonomic principles and activity pacing strategies 3
• Assess ability to perform activities of daily living and provide assistive devices as needed 3

Exercise Programs:

• Prescribe both range-of-motion and strengthening exercises for all patients 1, 4
• CMC joint exercises must target thumb-base mobility, muscle strength, and stability—these differ from interphalangeal joint exercises 2
• Apply heat therapy (paraffin wax or hot packs) before exercise sessions for symptomatic relief 2, 3

First-Line Pharmacological Management

Topical NSAIDs are the preferred initial pharmacological treatment due to moderate effect size (ES = 0.77) and superior safety profile compared to oral agents. 1, 2

• Topical NSAIDs show no increased gastrointestinal risk versus placebo (RR = 0.81) 2
• Preferred over systemic treatments, especially when only a few joints are affected 1, 3

Second-Line Pharmacological Management

If topical NSAIDs provide insufficient relief:

• Add acetaminophen up to 4g/day as the oral analgesic of first choice 2
• Note: Evidence for acetaminophen efficacy in hand OA is limited 3

Third-Line Pharmacological Management

When topical agents and acetaminophen fail:

• Use oral NSAIDs at the lowest effective dose for the shortest duration 1, 2
• In patients ≥75 years old, avoid oral NSAIDs entirely; continue topical NSAIDs regardless of response 2
• For increased gastrointestinal risk, use non-selective NSAIDs plus gastroprotective agent or selective COX-2 inhibitor 1
• NSAIDs should never be used immediately before or after coronary artery bypass graft surgery 5
• Monitor for cardiovascular, gastrointestinal, and renal adverse effects with prolonged use 5

Intra-articular Corticosteroid Injections:

• Generally not recommended for interphalangeal joints 1
• Consider for painful flares of CMC joint OA specifically 1, 2
• Effective for acute inflammatory episodes 3

Surgical Management

Surgery is indicated when marked pain and/or functional disability persist after ≥6 months of comprehensive conservative management including orthosis use, pharmacologic therapy, and targeted exercise. 2

• Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is the gold-standard operation for severe thumb CMC OA 2
• Total joint replacement may be considered but has limited comparative evidence 2
• Other options include interposition arthroplasty, osteotomy, or arthrodesis 1

Critical Pitfalls to Avoid

• Splinting duration error: Orthoses must be worn for minimum 3 months; shorter periods show no benefit 2
• Exercise prescription error: CMC-specific exercises are required; generic finger exercises are inadequate 2
• NSAID sequencing error: Exhaust topical NSAIDs before initiating oral NSAIDs 2
• Age-related prescribing error: Never use oral NSAIDs in patients ≥75 years; topical agents only 2

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Rheumatoid Arthritis of the Hand

Rheumatoid arthritis requires disease-modifying antirheumatic drugs (DMARDs) as the cornerstone of treatment, not NSAIDs or corticosteroids alone.

Pharmacological Management

DMARDs:

• Methotrexate is the anchor DMARD for RA and can be used concomitantly with biologic agents 6
• Adalimumab (anti-TNF biologic) has been studied with concomitant methotrexate; no dose adjustment needed 6
• Do not combine adalimumab with anakinra or abatacept due to increased infection risk without added benefit 6
• Avoid concomitant use of multiple biologic DMARDs or TNF blockers 6

Corticosteroids:

• Provide rapid symptom relief but do not alter disease progression 7
• Use low doses to limit toxicity 7

NSAIDs:

• Relieve symptoms but do not alter disease course 7
• Same safety precautions as for OA apply 5

Non-Pharmacological Management

• Joint protection education and ergonomic principles 8
• Exercise programs to maintain function 8
• Orthoses for symptomatic relief 8
• Adaptive equipment for activities of daily living 8

Important Drug Interactions

When using adalimumab or other biologics:

• Avoid live vaccines 6
• Monitor CYP450 substrates with narrow therapeutic index (warfarin, cyclosporine, theophylline) as TNF antagonism may influence enzyme formation 6
• Higher rate of serious infections observed when rituximab is followed by TNF blocker 1

Key Distinction from Osteoarthritis

Conventional or biological DMARDs should NOT be used in hand osteoarthritis 1, but they are essential for rheumatoid arthritis management. This fundamental difference in treatment approach reflects the distinct pathophysiology: RA is a systemic autoimmune disease requiring immunomodulation, while OA is primarily a degenerative joint disease managed with symptom control and mechanical interventions.