How do you manage patients with severe hand OA (no synovitis on exam, negative serologies) who fail to respond to NSAIDs but respond very well to oral steroids?

I have used Hydroxychloroquine with some success and offer that to patients for a trial for 4 months if they are willing.

I would consider looking for coexisting conditions, such as crystal disease, or hyper parathyroidism. A response to corticosteroids does not guarantee inflammatory disease. Imaging such as ultrasound (or even MRI) to include or exclude synovitis may be helpful.

The hand pain is likely mechanical in origin. Daily activities need to be reviewed and joint protection methodology pursued. Collaboration with an occupational therapist is critical. And, wean off the steroids.