What alternative treatments are available for hip pain in a patient with suspected rheumatoid arthritis, incomplete relief with ibuprofen and Voltaren gel, and a history of breast cancer, hyperlipidemia, hypertension, and insomnia?

Management of Hip Pain with Incomplete Response to NSAIDs

Do not start methotrexate for this patient—her negative inflammatory markers make rheumatoid arthritis highly unlikely, and methotrexate is contraindicated without confirmed inflammatory arthritis. 1

Immediate Next Steps

Obtain Plain Radiographs First

• Plain radiographs of the hip and pelvis should be your immediate next step before any additional interventions, as this is the recommended initial imaging for chronic hip pain and can guide all subsequent management decisions. 2
• Radiographs will differentiate between osteoarthritis (most likely given age and negative inflammatory markers), other structural pathology, or referred pain sources. 3
• The VA/DoD guidelines suggest against obtaining MRI for diagnosis of hip osteoarthritis initially. 2

Why Methotrexate is Inappropriate

• Methotrexate is indicated only for confirmed rheumatoid arthritis or other inflammatory arthropathies—not for suspected RA with negative serologies and inflammatory markers. 1
• Your patient's negative inflammatory markers argue strongly against RA, making empiric methotrexate both inappropriate and potentially harmful. 1
• Methotrexate carries significant risks including hepatotoxicity, bone marrow suppression, and pulmonary toxicity that require careful monitoring—risks that are only justified with confirmed inflammatory disease. 1
• Her history of breast cancer one year ago is a relative contraindication requiring careful consideration before starting any immunosuppressive therapy. 1

Optimize Current Pharmacologic Management

Maximize Oral NSAIDs

• Continue ibuprofen 800 mg three times daily with food (up to 2400 mg/day), as the maximum dose is 3200 mg/day and she may benefit from scheduled rather than as-needed dosing. 4
• Consider switching to a different NSAID if ibuprofen provides inadequate relief, as individual response varies. 2, 5
• Monitor for cardiovascular and gastrointestinal risks given her hypertension and hyperlipidemia. 2, 5

Add Acetaminophen

• Add scheduled acetaminophen 1000 mg every 6-8 hours (maximum 4000 mg/day) as first-line adjunctive therapy, which can be combined safely with NSAIDs. 6, 5
• Acetaminophen has a favorable safety profile and provides additive analgesia. 5

Consider Duloxetine

• If pain persists despite NSAIDs and acetaminophen, add duloxetine 30-60 mg daily as an alternative or adjunctive therapy for hip osteoarthritis pain. 2, 6, 5
• Duloxetine may also help with her insomnia as a secondary benefit. 2
• This is particularly appropriate given her contraindications to opioids (history of breast cancer, multiple comorbidities). 2

Interventional Options

Intra-articular Corticosteroid Injection

• Consider an intra-articular corticosteroid injection if radiographs confirm osteoarthritis and oral medications provide inadequate relief. 2, 5
• This can provide both diagnostic information (if pain improves, confirms intra-articular source) and therapeutic benefit lasting weeks to months. 2, 5
• Ultrasound or fluoroscopic guidance improves accuracy. 2

Avoid Hyaluronic Acid

• Do not offer intra-articular hyaluronic acid for hip pain—it is not recommended due to insufficient evidence. 2, 5

Non-Pharmacologic Interventions

Physical Therapy

• Refer to physical therapy as part of comprehensive management, focusing on hip strengthening, range of motion, and functional exercises. 2
• PT should be at least 3 months duration for optimal benefit. 2
• Include hip, trunk, and functional strengthening components. 2

Self-Management Program

• Recommend a structured self-management program including exercise and weight loss if she is overweight. 2, 5
• Land-based cardiovascular and resistance exercise or aquatic exercise programs are both effective. 6, 5

Assistive Devices

• Consider a cane for the contralateral hand to reduce joint loading. 5

What to Avoid

• Do not initiate opioids (including tramadol) for hip osteoarthritis pain—guidelines recommend against this due to poor risk-benefit ratio. 2, 6
• Do not prescribe glucosamine or chondroitin—these are not supported by current evidence for hip OA. 5
• Do not start methotrexate or other DMARDs without confirmed inflammatory arthritis. 1

Follow-Up Plan

• Review radiograph results at her 11/13 appointment to confirm diagnosis. 2, 3
• If radiographs show significant osteoarthritis unresponsive to conservative management, consider referral to orthopedic surgery for evaluation of total hip arthroplasty. 2, 5
• If radiographs are normal or show minimal changes, consider MRI to evaluate for labral tear, femoroacetabular impingement, or other intra-articular pathology. 2, 3
• Reassess pain control and medication tolerance at each visit. 6