A 68-year-old woman comes to the office due to worsening pain and stiffness in her hands for the past several months. The patient initially had pain in the fingers and at the base of the thumb only after prolonged gardening or sewing, but she is now having difficulty with daily activities such as buttoning her blouse or holding her dog's leash. Her fingers are stiff in the morning, with gradual improvement after 15-20 minutes of use. The patient has experienced no fever or swelling in the hands. She has attempted treatment of her pain with stretching exercises and over-the-counter acetaminophen without relief. Medical history is notable for hypertension, for which she takes amlodipine and lisinopril. The patient occasionally drinks alcohol but does not use tobacco or illicit drugs.
Vital signs are within normal limits. Hand examination shows no redness, swelling, or joint deformities, but passive and active range of motion elicits pain at the proximal and distal interphalangeal joints. The remainder of the examination is normal.
X-ray of the patient's hand is shown in the exhibit.
Which of the following is the most appropriate next step in management of this patient's symptoms?

Question

A 68-year-old woman comes to the office due to worsening pain and stiffness in her hands for the past several months.  The patient initially had pain in the fingers and at the base of the thumb only after prolonged gardening or sewing, but she is now having difficulty with daily activities such as buttoning her blouse or holding her dog's leash.  Her fingers are stiff in the morning, with gradual improvement after 15-20 minutes of use.  The patient has experienced no fever or swelling in the hands.  She has attempted treatment of her pain with stretching exercises and over-the-counter acetaminophen without relief.  Medical history is notable for hypertension, for which she takes amlodipine and lisinopril.  The patient occasionally drinks alcohol but does not use tobacco or illicit drugs.
Vital signs are within normal limits.  Hand examination shows no redness, swelling, or joint deformities, but passive and active range of motion elicits pain at the proximal and distal interphalangeal joints.  The remainder of the examination is normal.
X-ray of the patient's hand is shown in the exhibit.
Which of the following is the most appropriate next step in management of this patient's symptoms?

Quizplus · Accepted Answer

11ec193a_9943_d62c_853d_f3ed76c7a845_MD0002_00 This patient has chronic noninflammatory arthritis in the hands. Her x-ray shows joint space narrowing, subchondral sclerosis, and osteophyte formation in the distal interphalangeal (DIP) joints of multiple digits, particularly the second and the third. These findings are consistent with osteoarthritis (OA). The initial management of OA is determined by the joints involved, severity of symptoms, and comorbid conditions. OA of the large weight-bearing joints (eg, knees) often improves with an exercise and weight loss program. Initial medication options include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). However, systemic NSAIDs are associated with increased risk of complications in patients age ?65 (such as this patient) and in those with comorbid hypertension, heart disease, chronic kidney disease, or a history of gastrointestinal hemorrhage (Choice A). For these patients, a topical NSAID (eg, diclofenac) may be equally effective and associated with less systemic toxicity. (Choice B) The highest-quality studies on the use of glucosamine in OA have shown little benefit. It may have a small benefit in OA of the knee, but it is unlikely to be helpful for this patient. (Choices C and D) Serologic testing (eg, cyclic citrullinated peptide antibodies) is appropriate to screen for rheumatoid arthritis (RA) and other autoimmune disorders, and prednisone is often used in short courses in RA to provide initial relief while planning appropriate long-term management. However, RA is characterized by prolonged morning stiffness, palpable synovitis, and sparing of the DIP joints. This patient's noninflammatory arthritis that prominently affects the DIP joints is more consistent with OA. Educational objective: Initial medication options for osteoarthritis include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). However, systemic NSAIDs are associated with increased risk of complications in patients age ?65 and in those with hypertension, heart disease, chronic kidney disease, or a history of gastrointestinal hemorrhage. For these patients, a topical NSAID (eg, diclofenac) may be equally effective and is associated with less systemic toxicity. __________ References: Hand osteoarthritis-nonpharmacological and pharmacological treatments. (http://www.ncbi.nlm.nih.gov/pubmed/24468932)

A 68-Year-Old Woman Comes to the Office Due to Worsening