What are the recommended management options for an adult with symptomatic hip osteoarthritis?

Management of Hip Osteoarthritis

For symptomatic hip osteoarthritis, begin with acetaminophen up to 4 g/day combined with exercise therapy and weight loss, then escalate to topical NSAIDs before considering oral NSAIDs or intra-articular corticosteroid injections, reserving total hip arthroplasty for patients with marked quality-of-life impairment despite optimal non-operative care. 1

Initial Management (First 6 Weeks)

Pharmacologic Therapy

• Start with acetaminophen (up to 4 g/day) as the initial analgesic for hip osteoarthritis 1
• Apply topical NSAIDs directly to the affected hip(s) before escalating to oral NSAIDs 1
• Topical agents provide fewer systemic side effects than oral formulations and are particularly appropriate for localized joint pain 2

Non-Pharmacologic Core Interventions

• Prescribe exercise therapy focusing specifically on hip-muscle strengthening and aerobic conditioning 1
  • Land-based and aquatic exercises both improve pain and function 2
  • Supervised programs demonstrate superior effectiveness compared to unsupervised home regimens 1
• Initiate weight-loss counseling for patients with BMI > 25 kg/m² 1
  • A 5–10% body weight reduction yields clinically important improvements in pain and function 3
  • Benefits continue to increase up to 20% weight loss 3
• Provide patient education to counter misconceptions that osteoarthritis is inevitably progressive and untreatable 3

Adjunctive Measures

• Recommend assistive walking devices with shock-absorbing features to improve mobility and reduce joint loading 1, 2
• Consider physical modalities (local heat/cold, TENS, manual therapy) for temporary pain relief 2

Escalation Strategy (6–12 Weeks)

When Initial Therapy Is Insufficient

• Introduce oral NSAIDs or COX-2 inhibitors at the lowest effective dose if acetaminophen and topical NSAIDs provide inadequate relief 1
• Co-prescribe a proton-pump inhibitor for gastro-protection when using oral NSAIDs, especially in older adults 1
• Assess cardiovascular, gastrointestinal, and renal risk factors before prescribing NSAIDs, particularly in patients > 75 years 1
  • Use the lowest effective dose for the shortest duration to minimize adverse events 1
  • All oral NSAIDs and COX-2 inhibitors must be avoided in patients with uncontrolled hypertension 3

Interventional Options

• Offer intra-articular corticosteroid injection for moderate-to-severe hip pain unresponsive to oral therapy 1
  • Provides short-term pain relief lasting 1–3 weeks 3
  • Appropriate after 4–6 weeks of conservative management 3
• Add manual therapy (joint manipulation and stretching) combined with supervised exercise 1

Chronic Management (Beyond 12 Weeks)

Long-Term Conservative Care

• Continue a comprehensive strengthening exercise program indefinitely 1
• Maintain weight management and lifestyle modifications 2
• Tramadol 50 mg every 8 hours may be used PRN for breakthrough pain but should not replace the primary analgesic regimen 3

Surgical Referral

• Refer for total hip arthroplasty evaluation when hip symptoms markedly impair quality of life despite optimal non-operative care 1
• Joint replacement effectively relieves pain in patients with advanced symptoms and structural damage 4

Critical Safety Considerations

Medications to Avoid

• Opioids should be avoided as initial therapy due to limited benefit and high risk of harm 1
• Glucosamine, chondroitin, and hyaluronic-acid injections are not recommended because evidence does not support clinical benefit 1, 2, 5

Monitoring Requirements

• Re-assess pain intensity 2 weeks after initiating acetaminophen therapy 3
• Evaluate weight-loss progress and exercise adherence at 4–6 weeks 3
• Periodic review of treatment effectiveness is essential as disease course and patient needs change over time 2

Common Pitfalls to Avoid

• Do not prescribe oral NSAIDs without first assessing cardiovascular, renal, and gastrointestinal risk factors 1
• Do not exceed 4000 mg acetaminophen per day; a 3000 mg ceiling is preferred to limit hepatic risk 3
• Do not bypass topical NSAIDs and proceed directly to oral formulations 1
• Do not continue ineffective therapies—escalate or modify the regimen if no improvement occurs within 2–4 weeks 3
• Recognize that NSAIDs and corticosteroid injections are the most supported treatment options for hip osteoarthritis based on multiple society recommendations 6