What is the next step in managing hip pain for a 77-year-old patient with osteoarthritis, hypertension, type 2 diabetes mellitus, hyperlipidemia, gastroesophageal reflux disease (GERD), major depressive disorder, generalized anxiety disorder, and essential tremor, who is currently taking perindopril, amlodipine, metformin, gliclazide, empagliflozin, rosuvastatin, pantoprazole, escitalopram, naproxen, pregabalin, risedronate, calcium carbonate, vitamin D, and Premarin, and has already tried acetaminophen (Tylenol)?

Next Step in Hip Pain Management

Given that acetaminophen has failed and the patient is already on naproxen (which may be inadequate), the next step is to optimize the NSAID regimen by ensuring naproxen is dosed at 250-375 mg twice daily with mandatory co-prescription of a proton pump inhibitor (PPI) such as omeprazole 20 mg daily, while simultaneously initiating physical therapy. 1

Critical Safety Concern: NSAID Use in This Patient

This patient is already taking naproxen but appears to have inadequate pain control. Before escalating therapy, you must:

• Verify the current naproxen dose – ensure it is optimized at 250-375 mg twice daily 1
• Confirm PPI co-prescription – this patient has GERD and is on pantoprazole, which is appropriate, but the relative risk of gastric ulcer with NSAIDs alone is 5.36 compared to 0.40 when combined with a PPI 2
• Assess for contraindications – this patient is on perindopril (ACE inhibitor) and amlodipine, creating drug interaction concerns; NSAIDs can reduce antihypertensive efficacy and increase acute kidney injury risk, particularly with ACE inhibitors 2

Algorithmic Approach to Next Steps

Step 1: Optimize Current NSAID Therapy

• Ensure adequate dosing: Naproxen 250-375 mg twice daily (not just "as needed") 1
• Confirm PPI coverage: Continue pantoprazole 40 mg daily 1
• Monitor renal function: Check serum creatinine and eGFR within 1-2 weeks of optimizing NSAID dose, then every 3-6 months 1
• Monitor blood pressure: NSAIDs can worsen hypertension control 1

Step 2: Initiate Physical Therapy Immediately

• Structured exercise program targeting hip musculature strengthening 1
• Pool therapy in warm water to reduce joint loading and enhance pain-free motion 1
• Exercise has a significant effect size of 0.39 for pain relief and 0.31 for functional improvement in hip osteoarthritis 2, 3
• Avoid high-impact aerobic training as rapid load application may produce pain or damage 1

Step 3: Consider Additional Pharmacologic Options if NSAID Optimization Fails

If optimized NSAID therapy plus physical therapy provides inadequate relief after 2-4 weeks 1:

Option A: Add Duloxetine

• Duloxetine 30-60 mg daily is conditionally recommended for hip osteoarthritis 2
• Particularly useful given this patient's history of major depressive disorder and generalized anxiety disorder 2
• Can be used alone or in combination with NSAIDs 2

Option B: Consider Tramadol

• Tramadol 50-100 mg every 4-6 hours (max 400 mg/day) is a useful alternative when NSAIDs are contraindicated or ineffective 2, 3
• Caution: This patient is already on pregabalin; avoid combining tramadol with other CNS depressants outside highly monitored settings 2
• Tramadol may cause confusion in older patients and can reduce seizure threshold 2

Option C: Intra-articular Corticosteroid Injection

• Ultrasound-guided intra-articular glucocorticoid injection is strongly recommended for hip joints 2, 1
• Consider for patients with flare unresponsive to analgesics and NSAIDs 2
• Imaging guidance is mandatory for hip injection (unlike knee or hand) 2

Step 4: Non-Pharmacologic Adjuncts

• Weight reduction if overweight: Obesity increases hip OA risk (OR = 2.3) 2, 3
• Assistive device (cane): Reduces adverse mechanical forces across the joint 2, 3
• Patient education: Can reduce pain, though effect may be limited 3

Critical Pitfalls to Avoid

1. Do not add another NSAID – this patient is already on naproxen; adding ibuprofen or switching without clear rationale increases toxicity risk 2

2. Do not use diclofenac – higher cardiovascular event risk compared to other NSAIDs 1

3. Avoid opioids stronger than tramadol at this stage – narcotic medications should be preserved for postoperative periods or when all other options have failed 4

4. Do not combine tramadol with pregabalin without close monitoring – both are CNS depressants and this patient is elderly (77 years old), increasing risk of over-sedation and respiratory depression 2

5. Monitor for NSAID-related complications:

   • Acute kidney injury (especially with ACE inhibitor use) 2
   • Gastrointestinal bleeding (RR = 3.0 for NSAIDs) 2
   • Blood pressure elevation 1
   • Fluid retention (concerning with heart conditions) 2

Monitoring Plan

• Reassess pain and function at 2-4 weeks after optimizing NSAID therapy 1
• Renal function (creatinine, eGFR) at 1-2 weeks after NSAID optimization, then every 3-6 months 1
• Blood pressure at each visit 1
• Gastrointestinal symptoms at each visit; discontinue NSAIDs if dyspepsia, abdominal pain, or bleeding signs develop 1

When to Consider Surgical Referral

• Joint replacement should be considered if there is radiographic evidence of hip OA with refractory pain and disability despite optimal medical management 2
• Obtain anteroposterior and lateral radiographs of hip and pelvis to confirm OA severity and rule out other pathology 1