What is the recommended treatment for hand osteoarthritis in an adult with finger joint pain and stiffness?

Treatment of Hand Osteoarthritis

Start every patient with education, joint protection training, and a structured exercise program, then add topical NSAIDs as first-line pharmacologic therapy, reserving oral NSAIDs for patients who fail topical treatment. 1

Step 1: Core Non-Pharmacological Foundation (Required for All Patients)

These interventions form the backbone of treatment and should never be omitted, even when medications are added:

• Education and joint protection training must be provided to teach ergonomic principles, activity pacing, and proper use of assistive devices to avoid mechanical factors that accelerate joint damage 1, 2
• Structured daily exercise program combining range-of-motion and strengthening exercises improves function, increases muscle strength, and reduces pain with a moderate effect size of 0.32 1, 2
• Combined education plus exercise achieves a number-needed-to-treat of only 2 for global functional improvement, indicating substantial clinical benefit 2
• Heat application (paraffin wax or hot packs) for 15-20 minutes before exercise sessions enhances joint mobility 3, 1, 2
• Assistive devices (jar openers, tap turners, built-up utensil handles) should be provided to help perform activities of daily living without excessive joint stress 3, 2

Joint-Specific Orthoses

• Thumb-base (carpometacarpal) splints are strongly recommended for symptom relief when the first carpometacarpal joint is involved, with long-term use encouraged; splinting shows an effect size of 0.64 with a number-needed-to-treat of 4 3, 1, 2
• Interphalangeal joint orthoses help prevent or correct lateral angulation and flexion deformities 1

Step 2: First-Line Pharmacologic Therapy (Topical Agents)

When non-pharmacological measures alone are insufficient:

• Topical NSAIDs (diclofenac gel or ibuprofen cream applied 3-4 times daily) are the preferred initial pharmacologic therapy because of superior safety, especially for mild-to-moderate pain affecting only a few joints, with an effect size of 0.77 and number-needed-to-treat of 3 1, 2
• Topical capsaicin 0.025-0.075% applied as a thin film 3-4 times daily is an effective alternative topical agent with a number-needed-to-treat of 3 3, 1, 2
• For patients ≥75 years, topical NSAIDs are strongly preferred over oral NSAIDs due to reduced systemic exposure and superior safety profile 3, 2

Step 3: Second-Line Oral Analgesics

When topical treatments are insufficient:

• Paracetamol (acetaminophen) up to 4000 mg daily is the oral analgesic of first choice, with 92% expert consensus 1, 2
• Lower ceiling of 3000 mg daily is advised for older adults to enhance safety 1, 4
• Important caveat: Recent data question paracetamol's efficacy specifically in hand OA, though it remains the recommended first oral agent 1

Step 4: Third-Line Oral NSAIDs (Use With Extreme Caution)

Only after failure of paracetamol and topical agents:

• Use the lowest effective dose for the shortest possible duration with mandatory re-evaluation every 4-8 weeks 1, 2
• Risk stratification is mandatory before prescribing: assess gastrointestinal risk (prior ulcer, age ≥75 years, concurrent anticoagulation) and cardiovascular risk (history of MI, stroke, heart failure, hypertension) 1, 2

Risk-Based NSAID Selection Algorithm

• Increased GI risk: prescribe a non-selective NSAID plus proton-pump inhibitor (PPI), or use a COX-2 inhibitor 1, 2, 4
• Increased CV risk: COX-2 inhibitors are contraindicated; if NSAIDs are required, use non-selective agents with extreme caution 1, 2
• PPI co-prescription is recommended with all oral NSAIDs, particularly in elderly patients with gastrointestinal risk factors 1, 4

Step 5: Adjunctive Options for Persistent Symptoms

• Chondroitin sulfate may be added for modest pain relief and functional improvement, though effect sizes are small 1, 5
• Tramadol can be considered when NSAIDs are contraindicated or ineffective 3

Step 6: Intra-Articular Corticosteroid Injections (Selective Use)

• For thumb-base (carpometacarpal) OA: intra-articular corticosteroids are effective for managing painful inflammatory flares 1, 2
• For interphalangeal joints: may be considered during painful flares, but generally not recommended 1
• For wrist joints: intra-articular corticosteroids show no significant benefit and should not be used 1

Step 7: Surgical Referral (Last Resort)

• Surgery (trapeziectomy for thumb-base OA; arthrodesis or arthroplasty for interphalangeal OA) is reserved for patients with structural abnormalities causing marked pain and disability despite failure of conservative measures for 3-6 months 1, 2

Therapies to Avoid (Do Not Use)

• Conventional or biological DMARDs (methotrexate, hydroxychloroquine, anti-TNF agents) are contraindicated for hand OA 1, 2
• Glucosamine supplements are not recommended because evidence does not support clinical benefit 1, 5
• Intra-articular hyaluronic acid injections should not be used 1
• Opioid analgesics are conditionally recommended against due to risks outweighing benefits 3

Critical Pitfalls to Avoid

• Never initiate oral NSAIDs before trying topical NSAIDs, especially in patients ≥75 years 2
• Never prescribe oral NSAIDs without prior cardiovascular and gastrointestinal risk assessment 1, 2
• Never continue oral NSAIDs indefinitely—reassess necessity, efficacy, and emerging risk factors every 4-8 weeks 1, 2
• Never exceed 4000 mg daily of paracetamol, and strongly consider lower limits (3000 mg) in elderly patients 1, 4
• Never omit non-pharmacological interventions when adding medications—combined therapy is more effective than monotherapy 2

Treatment Individualization Factors

Tailor treatment intensity according to:

• Joint localization: thumb-base OA responds particularly well to splinting and intra-articular corticosteroids, whereas interphalangeal joints benefit more from orthoses 1, 2
• Presence of inflammation: inflammatory flares warrant intra-articular corticosteroid use 1, 2
• Severity of structural changes and symptoms: advanced structural damage with failed conservative therapy justifies earlier surgical referral 1, 2
• Patient age and comorbidities: cardiovascular disease, renal impairment, and gastrointestinal history significantly influence pharmacologic choices and risk-mitigation strategies 1, 2