What is the recommended initial treatment course, including non-steroidal anti-inflammatory drug (NSAID) regimen, for a patient with trochanteric bursitis, considering their medical history and potential gastrointestinal and renal function impairments?

NSAID Treatment Course for Trochanteric Bursitis

For trochanteric bursitis, NSAIDs should be prescribed at the lowest effective dose for 2-4 weeks as initial therapy, combined with local corticosteroid injection for optimal outcomes, with the understanding that NSAID monotherapy alone is insufficient in most cases. 1, 2

Initial NSAID Regimen

• Start with naproxen 500 mg twice daily or ibuprofen 600-800 mg three times daily for 2-4 weeks, as these are the most commonly studied NSAIDs for musculoskeletal conditions and have established safety profiles 3
• Prescribe NSAIDs on a scheduled basis rather than as-needed to maintain consistent anti-inflammatory levels, particularly during the first 2 weeks when inflammation is most active 3
• Limit the initial NSAID trial to 2-4 weeks maximum before reassessing response, as prolonged use without benefit increases risk without improving outcomes 3, 4

Critical Patient Assessment Before Prescribing

Cardiovascular Risk Stratification

• Avoid all NSAIDs in patients with recent myocardial infarction (within 6 months), recent cardiac stent placement, or immediately post-CABG surgery, as these represent absolute contraindications 3, 5
• For patients with established cardiovascular disease or risk factors, naproxen is the preferred NSAID with a relative risk of 0.92 for vascular events compared to other NSAIDs 5
• Never prescribe diclofenac to cardiac patients, as it carries a hazard ratio of 2.40 for death in post-MI patients 5

Gastrointestinal Risk Assessment

• Co-prescribe a proton pump inhibitor with any NSAID in patients over age 60, those with prior peptic ulcer disease, or those taking anticoagulants or corticosteroids, as these patients have a greater than 10-fold increased risk of GI bleeding 3, 4
• Avoid NSAIDs entirely in patients with active peptic ulcer disease or recent GI bleeding until the condition is fully resolved 3, 4

Renal Function Considerations

• Check baseline serum creatinine before initiating NSAIDs in elderly patients, those with diabetes, heart failure, or baseline renal impairment 4
• Completely avoid NSAIDs in patients with cirrhosis and ascites, as they precipitate acute renal failure through inhibition of compensatory prostaglandin-mediated renal vasodilation 6
• Never combine NSAIDs with ACE inhibitors, ARBs, or diuretics in patients with heart failure or cirrhosis, as this combination creates compounded nephrotoxicity 6, 5

Optimal Treatment Algorithm

First-Line Approach (Week 1-2)

• Combine scheduled NSAIDs with local corticosteroid injection into all four peri-trochanteric bursae (subgluteus maximus, subgluteus medius, subgluteus minimus, and trochanteric bursa proper), as this combination provides superior outcomes compared to either modality alone 7, 1, 8
• Use triamcinolone acetonide 40 mg mixed with 2% lidocaine 2-4 mL for the injection, as depot corticosteroids provide sustained anti-inflammatory effect 7
• Inject all four bursal sites in a single session rather than targeting only one or two areas, as inflammation typically involves the entire trochanteric quartet 8

Response Assessment (Week 2-4)

• If pain improves by 50% or more within 2 weeks, continue NSAIDs for a total of 4 weeks then discontinue, as most responsive cases show improvement within this timeframe 1, 2
• If pain persists beyond 2 weeks despite NSAIDs and injection, add physical therapy focusing on iliotibial band stretching and hip abductor strengthening rather than continuing NSAIDs indefinitely 1, 2
• Consider a second corticosteroid injection at 4-6 weeks only if initial response was partial (25-50% improvement), as 5.7% of patients require two injections for complete resolution 7

Refractory Cases (Beyond 6 Weeks)

• Discontinue NSAIDs after 6 weeks if symptoms persist, as continued use provides no additional benefit and only increases adverse event risk 1, 2
• Consider low-energy shock wave therapy as the next step, as level II evidence demonstrates superiority over continued conservative management in refractory cases 1
• Reserve surgical intervention (iliotibial band Z-plasty or bursectomy) for cases failing 3-6 months of comprehensive conservative therapy, as surgery shows superior VAS and Harris Hip Scores compared to prolonged medical management 1

Common Pitfalls to Avoid

• Never prescribe NSAIDs for longer than 4-6 weeks without documented objective improvement, as GI ulceration occurs in 1% of patients at 3-6 months and 2-4% at one year 4
• Do not assume all NSAIDs have equivalent cardiovascular risk—the differences are substantial, with naproxen being safest and diclofenac most dangerous 5
• Avoid ibuprofen in patients taking low-dose aspirin for cardioprotection, as ibuprofen negates aspirin's antiplatelet benefits through competitive COX-1 inhibition 5
• Never rely on NSAID monotherapy alone—only 7-15% of trochanteric bursitis cases respond to NSAIDs without corticosteroid injection 1, 2
• Do not inject only the point of maximal tenderness—all four peri-trochanteric bursae must be injected for optimal outcomes 8
• Counsel patients explicitly to avoid over-the-counter NSAIDs (ibuprofen, naproxen) if they have cirrhosis, heart failure, or are taking anticoagulants, as these combinations are dangerous 6, 5

Monitoring During NSAID Therapy

• Measure blood pressure at baseline and every 2 weeks during NSAID therapy, as NSAIDs cause mean increases of 5 mm Hg through COX-2-mediated sodium retention 5
• Monitor for signs of fluid retention, edema, or worsening heart failure weekly in cardiac patients, as NSAIDs can precipitate acute decompensation 3, 5
• Recheck serum creatinine at 1-2 weeks in high-risk patients (elderly, diabetic, heart failure, baseline renal impairment) to detect early nephrotoxicity 4
• Instruct patients to discontinue NSAIDs immediately and seek evaluation for any signs of GI bleeding (black stools, coffee-ground emesis, severe abdominal pain), as these events can occur without warning 4