From the Guidelines
For an 83-year-old female with right hip pain radiating to the leg, I recommend a multifaceted approach, prioritizing her reduced kidney function (eGFR 31, creatinine 1.63) and iron deficiency anemia. First, address the iron deficiency anemia indicated by low MCV, MCH, and elevated RDW with oral iron supplementation (ferrous sulfate 325mg once daily) as suggested by the British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults 1. For pain management, start with acetaminophen 650mg every 6 hours as needed, avoiding NSAIDs due to her reduced kidney function, in line with the American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee 1. Physical therapy should be initiated for strengthening exercises and gait training. The radiating pain suggests possible lumbar radiculopathy or sciatica, so a lumbar spine MRI would be appropriate to evaluate for nerve compression. Her kidney function requires monitoring, with nephrology consultation recommended for chronic kidney disease management, considering the European Myeloma Network guidelines for the management of multiple myeloma-related complications 1 and the management of cancer pain: ESMO clinical practice guidelines 1. The normal hip X-ray rules out fracture or significant arthritis as the pain source, directing our attention to potential neurological causes. A vitamin B12 and folate level should also be checked to fully evaluate her anemia. This comprehensive approach addresses both symptom management and underlying conditions while considering her advanced age and reduced kidney function. Key considerations include:
- Monitoring and managing her chronic kidney disease
- Avoiding NSAIDs due to renal impairment
- Careful use of opioids if necessary, considering her renal function
- Addressing potential neurological causes of her pain
- Evaluating and treating her iron deficiency anemia.
From the Research
Treatment Options
- For an 83-year-old female presenting with right hip pain that radiates to the right leg, treatment options should be considered based on the patient's overall health and medical history.
- The patient's CBC and CMP results, including MCV, MCH, MCHC, RDW-CV, and creatinine levels, should be taken into account when selecting a treatment plan 2, 3.
- The hip x-ray results, which show no significant changes in the appearance of the right hip, no significant arthritic changes or acute fracture/subluxation, and stable bone mineralization, should also be considered when developing a treatment plan.
Pharmacologic Treatment
- Acetaminophen may be considered as a first-line treatment for osteoarthritis-related pain, as it is generally well-tolerated and has a lower risk of adverse effects compared to NSAIDs and opioids 4, 5.
- Tramadol, a mild opioid agonist, may be recommended for patients who have not responded to previous oral therapy or have contraindications to COX-2 inhibitors and nonselective NSAIDs 2, 3.
- NSAIDs, including cyclooxygenase-2 (COX-2) inhibitors, may be considered for patients with osteoarthritis-related pain, but their use should be carefully monitored due to the risk of gastrointestinal, renal, and cardiovascular complications 2, 5.
Non-Pharmacologic Treatment
- Multidisciplinary biopsychosocial rehabilitation programs, which include exercise and education, may be beneficial for patients with chronic pain, including those with osteoarthritis-related pain 6.
- Other non-pharmacologic treatments, such as manipulation, massage, and acupuncture, may be considered, but their effectiveness is not well supported by evidence 6.