What is the usual treatment for hand osteoarthritis in an older adult presenting with gradual joint pain, stiffness, and decreased grip strength?

Treatment of Hand Osteoarthritis

Begin with education on joint protection and a structured exercise program for all patients, then add topical NSAIDs as first-line pharmacological therapy, reserving oral NSAIDs for inadequate responders. 1

Core Non-Pharmacological Treatments (Start Here for Every Patient)

• Education and joint protection training should be provided to every patient, teaching ergonomic principles, activity pacing, and proper use of assistive devices (Level 1b evidence, Grade A). 1

• Exercise programs involving both range of motion and strengthening exercises are essential for all patients to improve function, muscle strength, and reduce pain (Level 1a evidence, Grade A). 1

• Thumb base splints should be considered for symptom relief when the first carpometacarpal joint is affected, with long-term use advocated (Level 1b evidence, Grade A). 1 Splinting shows an effect size of 0.64 with a number needed to treat of 4 patients. 2

• Orthoses to prevent or correct lateral angulation and flexion deformity are recommended for affected interphalangeal joints. 1

• Local heat application (paraffin wax, hot packs) before exercise is beneficial, though ultrasound is not recommended. 1

Pharmacological Treatment Algorithm

First-Line: Topical Agents

• Topical NSAIDs are the first pharmacological treatment of choice due to superior safety over systemic treatments, especially for mild to moderate pain when only a few joints are affected (Level 1b evidence, Grade A). 1, 3 Topical NSAIDs show an effect size of 0.77 for hand osteoarthritis. 2

• Topical capsaicin is an effective alternative topical agent with a number needed to treat of 3 patients. 1, 2

Second-Line: Oral Analgesics

• Paracetamol (acetaminophen) up to 4000 mg daily is the oral analgesic of first choice if topical treatments are insufficient, though consider limiting to 3000 mg daily in elderly patients for enhanced safety. 1, 3 However, recent evidence questions its efficacy in hand OA. 4

• Oral NSAIDs should be used at the lowest effective dose for the shortest duration when paracetamol and topical treatments fail (Level 1a evidence, Grade A). 1 Oral NSAIDs show an effect size of 0.40 with a number needed to treat of 3 patients. 2

• Always co-prescribe a proton pump inhibitor with oral NSAIDs, particularly in elderly patients with gastrointestinal risk factors. 1

• COX-2 inhibitors are contraindicated in patients with cardiovascular risk; use non-selective NSAIDs with caution in this population. 1

Third-Line: Adjunctive Options

• Chondroitin sulfate may be used for pain relief and improved functioning (Level 1b evidence, Grade A), though effect sizes are small. 1, 5

• Intra-articular corticosteroid injections should NOT generally be used in hand OA, but may be considered specifically for painful interphalangeal joints during flares (Level 1a-1b evidence, Grade A). 1, 2 They are NOT effective for wrist joints. 2

• Intra-articular corticosteroids for thumb base OA are effective for painful flares. 1

What NOT to Use

• Do NOT prescribe conventional or biological DMARDs (methotrexate, hydroxychloroquine, anti-TNF agents) for hand osteoarthritis—these are contraindicated (Level 1a evidence, Grade A). 1, 2, 4

• Do NOT recommend glucosamine products, as evidence does not support their use. 1

• Do NOT use intra-articular hyaluronic acid injections. 1

• Avoid opioids as their benefits are outweighed by serious adverse events, particularly in elderly patients. 6

Surgical Intervention

• Surgery (trapeziectomy for thumb base OA, arthrodesis or arthroplasty for interphalangeal OA) should be considered only when structural abnormalities cause marked pain and disability despite conservative treatment failure (Level 5 evidence, Grade D). 1, 7

Critical Safety Pitfalls

• Never exceed 4000 mg daily paracetamol, and strongly consider 3000 mg limits in elderly patients to prevent hepatotoxicity. 3

• Never prescribe oral NSAIDs without gastroprotection in elderly patients, who face substantially higher risks of GI bleeding, renal insufficiency, and cardiovascular complications. 3, 2

• Reassess NSAID therapy periodically—use the lowest effective dose for the shortest duration, considering individual cardiovascular, gastrointestinal, and renal risk factors. 1, 8

Treatment Individualization

Treatment intensity should be adapted based on: 1, 2

• Localization (thumb base vs. interphalangeal joints)
• Severity of structural changes and symptoms
• Presence of inflammation (suggesting erosive OA)
• Level of pain, disability, and quality of life impact
• Comorbidities (cardiovascular disease, renal impairment, GI risk)
• Patient age and medication tolerance