What is the best initial treatment for a 63-year-old male with hip pain, type 2 diabetes, hypertension, peptic ulcer disease, and alcohol use disorder, with limited relief from acetaminophen?

Intra-articular Corticosteroid Injection is the Best Option

For this 63-year-old male with hip osteoarthritis and multiple contraindications to NSAIDs (peptic ulcer disease, age >60, alcohol use disorder, hypertension), intra-articular corticosteroid injection is the recommended treatment, as it provides effective short-term pain relief without the systemic risks posed by oral analgesics. 1

Why NSAIDs (Ibuprofen) Are Contraindicated

This patient has multiple high-risk factors that make NSAIDs extremely dangerous:

• Peptic ulcer disease history: This is an absolute contraindication to NSAIDs, as they cause gastrointestinal bleeding and perforation through COX-1 inhibition that removes gastric mucosal protection 2, 3
• Age >60 years: Increases risk of GI bleeding, renal complications, and cardiovascular events with NSAIDs 1, 2
• Alcohol use disorder: Significantly increases GI toxicity risk when combined with NSAIDs 2, 4
• Hypertension: NSAIDs cause sodium retention and increase blood pressure by an average of 5 mm Hg 2, 5
• Concurrent metoprolol use: Beta-blockers combined with NSAIDs increase nephrotoxicity risk 5

The American Geriatrics Society explicitly recommends avoiding NSAIDs in persons with peptic ulcer disease due to risk of GI bleeding, with relative risk of 14.6 when NSAIDs are used in patients with prior ulcer history 1, 4. Even COX-2 selective inhibitors offer no GI advantage and carry the same risks 6.

Why Oxycodone Is Not Appropriate

• Alcohol use disorder: This patient is already on naltrexone for alcohol use disorder, making opioid therapy problematic and potentially ineffective [@patient context@]
• Chronic pain management: Opioids are not recommended as first-line therapy for osteoarthritis pain 1
• Risk of addiction: Particularly concerning in patients with substance use history 1

Why Intra-articular Corticosteroid Is the Best Choice

Intra-articular corticosteroids provide effective short-term pain relief (1-24 weeks) for symptomatic knee and hip osteoarthritis without the systemic risks of oral medications 1. Three systematic reviews demonstrate efficacy at 1 week continuing through 16-24 weeks 1.

Advantages for This Patient:

• No GI toxicity: Avoids the peptic ulcer complications associated with NSAIDs 1
• No renal effects: Unlike NSAIDs, does not compromise renal perfusion 2, 5
• No cardiovascular risk: Does not increase blood pressure or cause sodium retention 2
• Effective for hip OA: The positive FABER test, pain with rotation, and radiographic findings (osteophytes, joint space narrowing) confirm hip osteoarthritis amenable to injection [@patient context@]

Why Hyaluronic Acid Is Less Preferred

While intra-articular hyaluronic acid is an option for osteoarthritis 6, the evidence for corticosteroids is stronger with Level II evidence and Grade B recommendation from the American Academy of Orthopaedic Surgeons 1. Corticosteroids provide more rapid pain relief compared to hyaluronic acid's delayed onset 1.

Acetaminophen Has Already Failed

The patient has "little relief from acetaminophen," so continuing or increasing acetaminophen alone is insufficient [@patient context@]. While acetaminophen up to 4g/day is recommended as first-line therapy 1, this patient requires escalation of care.

Clinical Algorithm for This Patient

1. Immediate: Intra-articular corticosteroid injection for hip OA 1
2. Continue: Acetaminophen up to 3g/day (not 4g due to alcohol use disorder) 1, 6
3. Consider: Topical NSAIDs for localized pain if needed, as they have minimal systemic absorption 6
4. Avoid completely: Oral NSAIDs (ibuprofen, naproxen, COX-2 inhibitors) 2, 5, 6
5. Avoid: Opioids given alcohol use disorder and naltrexone therapy 1

Important Pitfall to Avoid

Do not prescribe ibuprofen or any oral NSAID despite it being commonly used for osteoarthritis. This patient's peptic ulcer disease history creates a relative risk of 4.76 for subsequent GI events if NSAIDs are used 4. The combination of age >60, peptic ulcer disease, and alcohol use creates a "perfect storm" for life-threatening GI bleeding 1, 2, 4.