What is the best course of treatment for a patient experiencing anxiety and right hip pain, currently managed with Cymbalta (duloxetine) and seeking an increase in dosage, and also requesting a change in medication for hip pain, which is sharp, intermittent, and radiating to the lower back, exacerbated by activity and previously relieved with methocarbamol and diclofenac?

From the Guidelines

The patient's Cymbalta dosage should be increased to 60 mg/d, and diclofenac sodium 50mg twice daily with food should be added to manage her hip pain, while also increasing the frequency of methocarbamol for muscle relaxation, as these interventions are supported by the most recent and highest quality evidence for managing osteoarthritis and anxiety. The patient's symptoms of sharp, intermittent, and radiating hip pain, exacerbated by activity and worsening in the evenings, are consistent with osteoarthritis, and the use of duloxetine (Cymbalta) is suggested for treating patients with OA, as it has been shown to achieve significant reductions in pain outcomes and improve physical function 1. Additionally, the patient's history of good relief with diclofenac in the past supports the use of NSAIDs, which have exhibited superiority to acetaminophen in those with moderate-to-severe OA pain 1.

The patient's request for an increase in Cymbalta dosage is also supported by the evidence, as duloxetine should be initiated at doses 30 mg/d or more and increased to a goal of 60 mg/d 1. The use of methocarbamol for muscle relaxation can also be increased in frequency, as it has been providing relief for the patient.

Some key points to consider in the management of this patient's hip pain include:

• The use of topical agents, such as NSAIDs and capsaicin, may also be considered for OA of the knee, but the patient's symptoms are primarily in the hip, so diclofenac sodium 50mg twice daily with food is recommended 1.
• The patient should be educated on the importance of taking duloxetine daily and not discontinuing it without consulting their prescribing provider, and tapering over at least 2 to 4 weeks if discontinuation is necessary 1.
• Close monitoring for side effects, particularly gastrointestinal issues with diclofenac, will be important, and the patient should be advised to take the medication with food to minimize these risks.

Overall, the combination of increased Cymbalta dosage, diclofenac sodium, and increased frequency of methocarbamol targets different aspects of the patient's pain and anxiety, and is supported by the most recent and highest quality evidence for managing osteoarthritis and anxiety 1.

From the FDA Drug Label

After 7 weeks of treatment, duloxetine delayed-release capsules-treated patients with less than 30% reduction in average daily pain and who were able to tolerate 60 mg once daily had their duloxetine delayed-release capsules dosage, in a double-blinded fashion, increased to 120 mg once daily for the remainder of the trial Patients had a mean baseline pain rating of 6 on a numerical rating scale ranging from 0 (no pain) to 10 (worst possible pain). After 13 weeks of treatment, patients taking duloxetine delayed-release capsules 60 to 120 mg daily had a significantly greater pain reduction compared to patients taking placebo.

The patient is seeking an increase in the duloxetine (Cymbalta) dosage due to increased symptoms of anxiety. According to the drug label, patients who did not have a significant reduction in pain (<30% reduction) after 7 weeks of treatment with duloxetine 60 mg and were able to tolerate the dose, had their dosage increased to 120 mg in a double-blinded fashion.

Key points:

• The patient's current dosage is not specified.
• The patient is experiencing intermittent sharp hip pain that radiates to the lower back, which may be related to chronic musculoskeletal pain.
• The patient has been using methocarbamol and Tylenol with some relief and is requesting an increase in the frequency of methocarbamol and the addition of diclofenac.
• The decision to increase the duloxetine dosage should be based on the patient's individual response to treatment and tolerance of the medication.

Given the information provided, it is unclear whether the patient's current dosage of duloxetine should be increased. The patient's symptoms and response to treatment should be carefully evaluated before making any changes to their medication regimen 2.

From the Research

Patient's Condition

The patient is experiencing anxiety and right hip pain, with the anxiety symptoms worsening due to home life situations. The patient's right hip pain is described as sharp, intermittent, and radiating to the lower back, exacerbated by activity and worsening in the evening.

Medication

The patient is currently taking Cymbalta (duloxetine) for anxiety and is seeking an increase in dosage due to decreased effectiveness. The patient also reports that methocarbamol is helping with the hip pain and would like to increase the frequency of use. Additionally, the patient has used diclofenac in the past with good relief and is requesting this medication again.

Evidence for Duloxetine Use

• Duloxetine (Cymbalta) is a potent serotonin and noradrenaline reuptake inhibitor (SNRI) effective in the treatment of generalized anxiety disorder (GAD) 3.
• Duloxetine has been shown to be effective in the short-term treatment of patients with primary GAD of at least moderate severity, with significant improvements in anxiety and functional impairment 3.
• Duloxetine is generally well tolerated, with most adverse events being of mild to moderate severity 3, 4.
• Duloxetine may be considered an effective treatment option for anxiety disorders individually or in comorbidity with major depressive disorder (MDD) 5.

Evidence for Pain Management

• Duloxetine has been shown to be effective in the treatment of painful physical symptoms associated with depression 4.
• A systematic review found that duloxetine was effective in treating pain in patients with MDD, although the evidence was limited 6.
• The patient's use of methocarbamol and diclofenac for hip pain suggests that these medications may be effective in managing the patient's pain symptoms.

Considerations for Treatment

• The patient's request for an increase in Cymbalta dosage should be considered in light of the evidence for duloxetine's effectiveness in treating anxiety and pain symptoms 3, 4.
• The patient's use of methocarbamol and diclofenac for hip pain should be monitored and adjusted as needed to ensure effective pain management.
• The patient's overall treatment plan should be regularly reviewed and updated to ensure that it remains effective and safe.