What is the next best treatment option for an elderly patient with rheumatoid arthritis (RA) and severe osteoarthritis of the shoulder, including frozen shoulder, who has not responded to naproxen and lives alone?

Next Best Treatment for Elderly Patient with RA, Severe Shoulder OA, and Frozen Shoulder After Naproxen Failure

For this elderly patient living alone with inadequate response to naproxen, initiate a structured physical therapy program with isometric shoulder exercises combined with topical NSAIDs, and consider intra-articular corticosteroid injection for the frozen shoulder component. 1

Immediate Non-Pharmacological Interventions (First Priority)

Exercise therapy is the cornerstone of treatment and must be implemented immediately, focusing on:

• Isometric strengthening exercises specifically for the rotator cuff and scapular stabilizers, as these are particularly important when joints are acutely inflamed or unstable 2, 1
• Begin with low-intensity isometric contractions (approximately 30% of maximal voluntary contraction) and gradually increase to 75% as tolerated 2
• Hold contractions for no longer than 6 seconds, starting with one contraction per muscle group and gradually increasing to 8-10 repetitions 2
• Static stretching exercises performed daily when pain and stiffness are minimal, holding terminal stretch positions for 10-30 seconds 2
• Apply local heat (paraffin wax or hot packs) before exercise sessions for temporary pain relief 1

Critical consideration for living alone: Since this patient has no recent falls, they can safely perform home exercises, but initial supervised physical therapy is essential to ensure proper technique and prevent injury 2, 1

Pharmacological Management Algorithm

Step 1: Topical NSAIDs (Immediate Next Step)

• Switch from oral naproxen to topical NSAIDs as they are effective with minimal systemic exposure and should be considered before escalating to other oral agents 2, 1
• This is particularly important in elderly patients (age ≥75 years) where topical formulations are conditionally recommended over oral NSAIDs 2

Step 2: Alternative Oral Analgesics

If topical NSAIDs provide insufficient relief:

• Tramadol 50-100 mg every 4-6 hours is particularly useful in the elderly population because it does not aggravate hypertension or congestive heart failure, nor does it cause peptic ulcer disease unlike NSAIDs 2, 3
• Tramadol has minimal respiratory depression and constipation compared to traditional opioids 3
• Important: Start with slow dose titration to minimize nausea, which occurs early in treatment 3

Step 3: Intra-Articular Corticosteroid Injection

For the frozen shoulder component specifically:

• Glenohumeral intra-articular corticosteroid injection is particularly effective for moderate to severe pain flares and frozen shoulder in diabetic and non-diabetic patients 1, 4
• Research shows equivalent efficacy between intra-articular corticosteroids and NSAIDs for frozen shoulder, but the injection provides more targeted relief 4
• This can be combined with the exercise program for optimal results 4

Additional Pharmacological Options

If Above Measures Insufficient:

• Topical capsaicin can be added as an adjunct for localized pain relief 2
• Short-term oral corticosteroids (prednisone) may be considered for acute inflammatory flares, as it is FDA-indicated for "synovitis of osteoarthritis" and "acute and subacute bursitis" 5

Critical Safety Considerations for Elderly Patients

Before prescribing any systemic NSAIDs or escalating therapy:

• Assess cardiovascular, gastrointestinal, and renal risk factors 2, 1
• If oral NSAIDs are necessary despite topical failure, use the lowest effective dose for the shortest duration with mandatory proton pump inhibitor for gastroprotection 1

Common Pitfalls to Avoid

• Do not continue ineffective oral NSAIDs - the patient has already failed naproxen, so switching to topical formulations or alternative analgesic classes is more appropriate than trying another oral NSAID 2
• Do not skip exercise therapy - medications alone are insufficient; the evidence strongly supports exercise as essential for improving pain and function 2, 1
• Do not overlook the frozen shoulder component - this requires specific intervention with intra-articular injection and targeted stretching 1, 4
• Avoid excessive joint activity - joint pain lasting 1 hour after exercise and joint swelling indicate excessive activity and require modification 2

Monitoring and Follow-Up

• Reassess at 6-12 weeks to determine if escalation of therapy is needed 1
• Monitor for treatment effectiveness as disease course and patient needs change over time 1
• If comprehensive conservative treatment fails after 3-6 months, consider orthopedic referral for surgical evaluation 1