What is the recommended initial treatment for osteoarthritis of the right hip in a patient with type 2 diabetes, hypertension, atrial fibrillation, peptic ulcer disease, alcohol use disorder, and obesity?

Recommended Treatment for Hip Osteoarthritis

Intra-articular corticosteroid injection is the most appropriate next step for this patient, given his multiple contraindications to NSAIDs and the strong evidence against both opioids and hyaluronic acid for hip osteoarthritis. 1

Why NOT the Other Options

Ibuprofen (and NSAIDs) - Contraindicated

This patient has three absolute contraindications to NSAIDs that make ibuprofen inappropriate:

• Peptic ulcer disease: NSAIDs significantly increase risk of GI bleeding and ulcer recurrence 1
• Anticoagulation with apixaban: Concurrent NSAID use dramatically increases bleeding risk in patients on direct oral anticoagulants 1
• Alcohol use disorder: Increases both GI toxicity and hepatotoxicity risk with NSAIDs 1

While NSAIDs are conditionally recommended for hip OA in patients without contraindications 1, this patient's comorbidities make them unsafe.

Oxycodone - Strongly Discouraged

The 2023 American Academy of Orthopaedic Surgeons guidelines explicitly state that oral opioids should not be used for treatment of symptomatic hip OA (consensus strength of option). 1 Opioids are reserved only for patients who have failed all other modalities and are unwilling or unable to undergo total hip arthroplasty. 1 This patient has not yet exhausted appropriate conservative options.

Intra-articular Hyaluronic Acid - Not Recommended

The 2023 AAOS guidelines provide a strong recommendation against hyaluronic acid injection for hip OA based on high-quality evidence showing lack of efficacy. 1 This is one of the strongest negative recommendations in the guidelines and should not be considered.

Why Intra-articular Corticosteroid Injection IS Appropriate

Guideline Support

• The 2023 AAOS guidelines state that intra-articular corticosteroids could be considered for symptomatic hip OA with moderate strength of recommendation based on high-quality evidence 1
• The 2012 ACR guidelines conditionally recommend intra-articular corticosteroid injections for hip OA 1
• This intervention is specifically mentioned as appropriate for patients who have inadequate response to acetaminophen (which this patient has tried at maximum dose) 1, 2

Evidence of Efficacy

• Randomized controlled trials demonstrate that intra-articular corticosteroid injections provide pain relief and functional improvement lasting up to 12 weeks in hip OA 3
• Studies show significant reduction in pain at rest and with weight-bearing, improved range of motion, and enhanced functional ability at 3-week follow-up 4
• Corticosteroids provide the best short-term relief compared to other injectable options 5

Safety Profile

• With proper sterile technique and fluoroscopic or ultrasound guidance, the risk of adverse outcomes is very low 6
• This is particularly important given the hip joint's proximity to neurovascular structures 7
• The systemic absorption is minimal compared to oral corticosteroids 7

Clinical Implementation Algorithm

Step 1: Confirm the diagnosis and severity

• This patient has radiographic confirmation of severe hip OA with osteophytes and joint space narrowing 1
• Physical examination confirms intra-articular pathology (positive FABER, pain with rotation, decreased ROM) 1

Step 2: Ensure proper injection technique

• Fluoroscopic or ultrasound guidance is mandatory for hip injections due to the deep location and adjacent neurovascular structures 7, 6
• Use strict sterile technique to minimize infection risk 6

Step 3: Set realistic expectations

• Inform the patient that pain relief typically lasts 6-12 weeks 3, 6
• This is a temporizing measure while optimizing for potential total hip arthroplasty 1
• The injection does not alter disease progression 4

Step 4: Concurrent optimization

• Continue weight loss efforts (BMI 34 increases surgical risk) 1
• Initiate physical therapy with land-based and aquatic exercises 1, 2
• Consider referral to orthopedics for surgical evaluation given severe radiographic changes 1

Common Pitfalls to Avoid

• Do not perform blind injections: The hip joint cannot be reliably accessed without imaging guidance 7, 6
• Do not use hyaluronic acid: Despite its use in knee OA, it has no proven efficacy in hip OA 1
• Do not prescribe opioids at this stage: The patient has not exhausted appropriate conservative options 1
• Do not ignore surgical candidacy: With severe radiographic changes and failed conservative management, this patient should be evaluated for total hip arthroplasty 1

Follow-up Plan

• Reassess pain and function at 2-4 weeks post-injection to evaluate response 3, 4
• If adequate relief is achieved, use this window to optimize weight, diabetes control (for future surgery), and physical therapy 1
• If relief is inadequate or wears off quickly, proceed with orthopedic referral for surgical evaluation 1
• The injection can be repeated, though evidence for optimal timing and frequency is limited 3, 6