What is the recommended treatment for a hip arthritis flare-up?

Treatment of Hip Arthritis Flare-Up

For hip arthritis flare-ups, NSAIDs at the lowest effective dose should be the first-line pharmacological treatment, combined with non-pharmacological approaches including rest, activity modification, and supportive devices. 1, 2

Step-by-Step Management Algorithm

First-Line Treatment

1. Non-pharmacological interventions:

   • Rest and activity modification to avoid aggravating activities
   • Use of supportive devices (walking sticks, insoles) as needed
   • Weight reduction if overweight or obese
   • Structured exercise program (at least 3 times weekly for 30 minutes)

2. Pharmacological treatment:

   • NSAIDs for 1-3 weeks:
     • Naproxen 500mg twice daily OR
     • Ibuprofen 400-800mg three to four times daily (total 1200-3200mg daily)
     • Use lowest effective dose for shortest duration
     • NSAIDs show significant pain relief with effect size of 0.69 (95% CI 0.12 to 1.26) and NNT of 4 (95% CI 3 to 6) 1, 2

Second-Line Treatment (if inadequate response to first-line)

1. For patients with increased GI risk:

   • Non-selective NSAIDs plus gastroprotective agent OR
   • COX-2 selective inhibitor 1

2. Alternative pharmacological options:

   • Paracetamol/Acetaminophen (up to 4g/day) for mild-moderate pain 1, 2
   • Opioid analgesics with or without paracetamol when NSAIDs are contraindicated, ineffective, or poorly tolerated 1

For Persistent Flare-Ups (unresponsive to above measures)

• Intra-articular corticosteroid injection guided by ultrasound or x-ray 1, 2
  • Indicated when symptoms persist despite 2-3 weeks of conservative therapy
  • Effective with reported 80% resolution rate in some studies 2
  • Avoid multiple repeated injections due to potential tissue damage

Special Considerations and Precautions

NSAID Safety Concerns

• Gastrointestinal risks: Higher in elderly, those with history of peptic ulcer, or concomitant use of corticosteroids or anticoagulants 3
• Cardiovascular risks: Use with caution in patients with hypertension, heart failure, or history of cardiovascular disease 3
• Renal risks: Monitor renal function in elderly patients and those with pre-existing renal disease 3

Medication Selection Based on Patient Factors

• For elderly patients or those with comorbidities: Consider starting with lower doses of NSAIDs or using acetaminophen
• For patients with severe pain: Higher doses of NSAIDs (e.g., ibuprofen 600-800mg TID/QID) may be more effective 4, 5
• For patients with cardiovascular risk: Naproxen may have a slightly better cardiovascular safety profile than other NSAIDs 6

Long-term Management Considerations

• Tailor treatment according to:

  • Hip risk factors (obesity, mechanical factors, physical activity, dysplasia)
  • General risk factors (age, sex, comorbidity, co-medication)
  • Pain intensity, disability level
  • Structural damage
  • Patient preferences 1

• For patients with persistent symptoms despite optimal medical management, consider referral for surgical evaluation, particularly in younger adults with dysplasia or varus/valgus deformity 1

Remember that the goal of treatment is to reduce pain, improve function, and minimize medication-related adverse effects. The combination of non-pharmacological and pharmacological approaches provides the most effective management strategy for hip arthritis flare-ups.