From the Guidelines
The patient's current treatment plan for anxiety and right hip pain should be optimized by continuing Cymbalta (duloxetine) at its current dose, as it has been effective in managing her anxiety, and considering alternative pain management options for her hip pain, such as acetaminophen and/or oral NSAIDs, as recommended by the 2020 VA/DoD Clinical Practice Guideline for the Non-Surgical Management of Hip & Knee Osteoarthritis 1.
The patient is a female presenting for follow-up regarding anxiety and right hip pain. She reports that her anxiety has improved with Cymbalta (duloxetine), though she is requesting a dosage increase. Her right hip pain is described as sharp, intermittent, and radiating to her lower back, worsening with activity and in the evenings. She has been using methocarbamol and Tylenol for pain management with partial relief and recalls having good results with diclofenac in the past.
- The patient's weight gain is likely attributed to her increased consumption of fried chicken, rather than Cymbalta, as she has realized.
- She recently obtained insurance coverage and requests referrals to physical therapy and orthopedics for her hip pain.
- The patient would like to increase the frequency of methocarbamol and add diclofenac to her pain management regimen. However, the use of duloxetine for pain management is supported by a systematic review that found significant reductions in pain outcomes for patients with osteoarthritis, and it is recommended to be initiated at doses of 30 mg/d or more and increased to a goal of 60 mg/d 1.
- The patient's current pain management regimen includes methocarbamol and Tylenol, which have provided partial relief.
- The addition of diclofenac, an oral NSAID, may be considered as it has exhibited superiority to acetaminophen in patients with moderate-to-severe osteoarthritis pain, as recommended by the 2020 VA/DoD Clinical Practice Guideline for the Non-Surgical Management of Hip & Knee Osteoarthritis 1.
- Referral to physical therapy is also recommended, as it is considered an essential component of the non-surgical management of hip and knee osteoarthritis, and early referral is suggested based on pain severity, functional limitations, and adherence 1.
- Furthermore, the American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee conditionally recommend the use of oral NSAIDs, such as diclofenac, for the initial management of knee OA, and suggest that health care providers do not use oral NSAIDs in patients with contraindications to these agents 2.
From the FDA Drug Label
Patients in all trials had no signs of radiculopathy or spinal stenosis. Study CLBP-1: Two hundred thirty-six adult patients (N=115 on duloxetine delayed-release capsules, N=121 on placebo) enrolled and 182 (77%) completed 13-week treatment phase 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
The patient's History of Present Illness (HPI) is as follows:
- The patient presents with anxiety related to home life situations and right hip pain described as sharp, intermittent, and radiating to the lower back.
- The pain is exacerbated by activity and worsens in the evening.
- The patient is currently taking Cymbalta (duloxetine) for anxiety, which has helped a lot, but is seeking a dosage increase.
- The patient reports an increase in eating fried chicken and initially attributed their weight gain to Cymbalta, but now realizes it is likely due to their diet.
- The patient has been using methocarbamol and Tylenol for hip pain with some relief and reports a previous good response to diclofenac.
- The patient requests increasing methocarbamol frequency and adding diclofenac to better manage hip pain symptoms.
- The patient has recently gained insurance and would like a referral back to PT and an ortho referral for evaluation of hip pain 3, 4.
From the Research
History of Present Illness
- The patient presents for follow-up on anxiety related to home life situations and right hip pain described as sharp, intermittent, and radiating to the lower back 5.
- The pain is exacerbated by activity and worsens in the evening.
- The patient is currently taking Cymbalta (duloxetine) for anxiety, which has helped a lot, but is seeking a dosage increase 6, 7, 8.
- The patient reports an increase in eating fried chicken and initially attributed weight gain to Cymbalta, but now realizes it is likely due to dietary habits.
- The patient has been using methocarbamol and Tylenol for hip pain with some relief and reports a previous good response to diclofenac.
- The patient requests increasing methocarbamol frequency and adding diclofenac to better manage hip pain symptoms.
- The patient has recently obtained insurance and would like a referral back to physical therapy (PT) and an orthopedic referral for evaluation of hip pain.
Medications
- Cymbalta (duloxetine) for anxiety 6, 7, 8
- Methocarbamol for hip pain
- Tylenol for hip pain
- Diclofenac (requested to be added for hip pain)
Treatment Plan
- Monitor patient's response to current medications and adjust as needed
- Refer patient to PT for further evaluation and treatment of hip pain
- Refer patient to orthopedic specialist for evaluation of hip pain 5
- Consider increasing methocarbamol frequency and adding diclofenac for hip pain management
- Encourage patient to continue monitoring dietary habits and their impact on weight gain