A 51-year-old woman comes to the office due to pain in her hands. For the past 2 years, she has had daily pain and stiffness in the fingers that are worse when working with hand tools or opening food jars. The patient has tried massaging her hands and doing stretching exercises, with only partial relief. Medical history is unremarkable, and she takes no medications. Vital signs are normal. Examination reveals mild, hard periarticular enlargement at multiple proximal and distal interphalangeal joints of both hands, as shown in the image below: Examination of the metacarpophalangeal joints and wrists is normal. Which of the following is the most appropriate therapy for management of this patient's symptoms?

Question

A 51-year-old woman comes to the office due to pain in her hands.  For the past 2 years, she has had daily pain and stiffness in the fingers that are worse when working with hand tools or opening food jars.  The patient has tried massaging her hands and doing stretching exercises, with only partial relief.  Medical history is unremarkable, and she takes no medications.  Vital signs are normal.  Examination reveals mild, hard periarticular enlargement at multiple proximal and distal interphalangeal joints of both hands, as shown in the image below:  Examination of the metacarpophalangeal joints and wrists is normal.  Which of the following is the most appropriate therapy for management of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d2ed_0be0_bc81_7df6c57f6d53_MD0003_00 This patient has pain and stiffness consistent with early osteoarthritis (OA) of the hands. OA typically becomes symptomatic at age >40, and patients commonly report worsening of symptoms with extensive use of hand tools or other strenuous motor tasks (eg, opening jars). OA of the hands is primarily a clinical diagnosis; distal interphalangeal joint involvement is classic, and bony enlargement at the distal and proximal interphalangeal joints (ie, Heberden and Bouchard nodes) is pathognomonic for OA and often associated with a strong family history of the condition. Heberden and Bouchard nodes Initial management of hand OA includes stretching and strengthening exercises. Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce prostaglandin-induced sensitization of peripheral nociceptors and are effective for pain relief in patients with OA. Topical NSAIDs (eg, diclofenac) are adequate for most patients; oral NSAIDs are also effective but carry a greater risk for toxicity (eg, peptic ulcer). (Choice A) Glucosamine is sometimes suggested for management of knee OA, although evidence of its benefit is mixed. It is not well studied for OA of the hands, and any benefits are likely negligible. (Choices B and C) Systemic glucocorticoids (eg, prednisone) are used for acute symptomatic management of rheumatoid arthritis (RA), whereas methotrexate is used chronically to minimize long-term RA joint destruction. Although RA can affect the interphalangeal joints, it is more common in the metacarpophalangeal joints and wrists, and the joint swelling is typically rubbery or spongy, rather than hard and bony. In addition, distal interphalangeal joint involvement can occur in RA but should raise suspicion for OA. Although intraarticular glucocorticoids are occasionally used for patients with refractory hand (especially thumb) OA, systemic glucocorticoids are not recommended. (Choice E) Other medications that can provide pain relief in OA include duloxetine, tramadol, and low-dose opioids. However, these drugs are not usually necessary for patients with early or mild disease and can cause nausea, vomiting, dizziness, and constipation. Therefore, they are generally considered only when OA does not respond to NSAIDs. Educational objective: Initial management of hand osteoarthritis includes stretching and strengthening exercises. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, diclofenac) are beneficial for most patients; oral NSAIDs are also effective but carry a greater risk for toxicity (eg, peptic ulcer). References: Efficacy and safety of non-pharmacological, pharmacological and surgical treatment for hand osteoarthritis: a systematic literature review informing the 2018 update of the EULAR recommendations for the management of hand osteoarthritis. (http://www.ncbi.nlm.nih.gov/pubmed/30402266) Use of NSAIDs in treating patients with arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/24267197)

A 51-Year-Old Woman Comes to the Office Due to Pain