A Case of Osteoarthritis and Cardiovascular Disease Presenting with Bilateral Hip Pain

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SCIENCE
A Case of Osteoarthritis and Cardiovascular Disease Presenting with Bilateral Hip Pain

A 79-year-old Caucasian retired physician presented to the clinic with a severe complaint of bilateral hip pain that had been persisting since last 2 years with unbearable episodes of pain over the previous three months. His pain was dull and achy, and started anteriorly in both the hips with occasional radiation to the groin. The pain ratings at its most severe point were 7 and 5 on a ten-point scale in the left and the right hip, respectively. The pain was most severe in the morning, when the patient woke up and in the evening after completion of all day to day activities. Acetaminophen 650mg bid as well as tid was no longer effective in relieving his pain. However, Ibuprofen 400 mg tid did show some improvement. The patient was unwilling to begin NSAIDs because of the fear of having gastrointestinal (GI) adverse events. Tramadol, hydrocodone, and oxycodone in the past lead to troublesome lightheadedness.

What will most likely explain the symptoms reported by the patient in this case?

  • Bilateral Hip Osteoarthritis
  • Spinal Stenosis
  • Greater Trochanteric Bursitis
  • Osteonecrosis

 

Introduction

Osteoarthritis (OA) is the most common joint disorder in the United States and a leading cause of disability in the elderly population. Approximately 5% of the population over the age of 65 years has radiographic evidence of OA of the hip and nearly 20, 0000 total hip replacements are performed annually.1 The management of osteoarthritis starts with the administration of acetaminophen and NSAIDs (Non Steroidal Anti Inflammatory Drugs). Although, NSAIDs are not efficacious in all patients because of reported gastrointestinal and cardiovascular adverse effects.

Medical History

His past medical history included coronary artery disease and three prior myocardial infarctions (MIs), the most recent being just 2 years earlier. He was prescribed aspirin 81mg once daily to relieve his pain. He had no history of peptic ulcer disease, upper GI bleeding or any other bleeding disorders, liver or kidney disease, chronic steroid use, excessive alcohol intake, history of trauma, and any other symptoms of joint pain.

Examination and Laboratory Investigations

Physical examination: He was able to walk without an assistive device but demonstrated a slightly antalgic gait. Hip internal rotation was painful and limited to 15° bilaterally. External rotation was 50° on the right side and 40° on the left side.

Flexion-Abduction-External Rotation (FABER test) provocative testing produced hip pain bilaterally. Sensation was intact to light touch. Examination of the patient's knees demonstrated mild crepitus bilaterally, and results of a lumbar spinal examination were unremarkable. The patient met the American College of Rheumatology clinical criteria for OA of the hip, which was hip pain plus hip internal rotation of ≥15°, pain with hip internal rotation, morning stiffness of the hip for ≤60 minutes, and age >50 years or hip pain plus hip internal rotation of <15° and erythrocyte sedimentation rate (ESR) of ≤45 mm/hr or hip flexion of <115° if the ESR is not known.

Management

Treatment included over-the-counter (OTC) naproxen 220 mg every 12 hours in conjunction with the PPI omeprazole 20 mg once daily. The patient was advised by physician of the warnings regarding naproxen related to cardiovascular and GI adverse events as well as other possible side effects. He was also advised to start a program of physical therapy and recommended to continue acetaminophen 650 mg up to four times per day as needed. Four weeks later, the patient rated his pain as 5 and 2 on a ten-point scale in the left and the right hip, respectively. The physical therapist recommended a straight cane which was very helpful in alleviating some of his pain during walking. There were no adverse GI effects and the patient was pleased with his treatment and progress. The patient follow up visit was scheduled after 2 months when he would complete his course of physical therapy. However, he was to instructed to continue his home exercise program and adhere to his medication regimen.

Discussion

Treatment for osteoarthritis includes both non pharmacological and pharmacological therapies. The pharmacological treatment should start only after assessment of risk factors and medical co-morbidities. Treatment begins with acetaminophen or a non selective NSAID, such as naproxen or ibuprofen. However, non selective NSAIDs should be used with caution because of GI side effects. Many observational studies proved that the addition of proton pump inhibitor (PPI) to NSAID therapy prevents the risk of peptic ulcer bleeding by 82%.3 Both ibuprofen and naproxen is available in market in different strengths. The occurrence of adverse GI side effects in patients taking OTC doses of naproxen (up to 660 mg/day) have been shown to be comparable to, and in some cases lower than that in patients taking placebo.4 In patients with OA already taking aspirin for cardio protection, certain NSAIDs may interfere the antithrombotic action of aspirin because of competitive interaction with platelet COX-1. As a result, the use of ibuprofen in patients at increased CV risk could limit the cardio protective effects of aspirin. 4,5 Post hoc analysis TARGET (Therapeutic Arthritis Research and Gastrointestinal Event Trial) study showed that among patients at high CV risk already taking aspirin, the incidence of CV events was significantly higher in the subgroup taking ibuprofen but not in the subgroup taking naproxen when each was compared with lumiracoxib.6 So, concomitant use of acetaminophen or naproxen does not reduce the COX-1-mediated platelet inhibition induced by aspirin, suggesting that these two medications may be safer choices in patients at higher CV risk who are receiving aspirin therapy.7,8,9

Learning  

The use of OTC naproxen together with proton pump inhibitor and low dose aspirin proved to be effective in the treatment of OA of the hip in the case study of patient with OA of the hip with cardiovascular and GI risk factors. Physical therapy demonstrated an important role in alleviating the pain that occurs while walking in such a patient.

References:

  1. Lane N. Osteoarthritis of the hip. N Engl J Med. 2007; 357:1413–1421.
  2. C.K.S. Ong, DDS, PhD, P. Lirk, MD, C.H. Tan, MD, PhD, and R.A. Seymour,An Evidence-Based Update on Nonsteroidal Anti-Inflammatory Drugs.Clin Med Res. 2007 Mar; 5(1): 19–34.
  3. Ray WA, Chung CP, Stein CM, Smalley WE, Hall K, Arbogast PG, Griffin MR. Risk of peptic ulcer hospitalizations in users of NSAIDs with gastro protective cotherapy versus coxibs. Gastroenterology. 2007; 133:790–798.
  4. Catella-Lawson F, Reilly MP, Kapoor SC, Cucchiara AJ, DeMarco S, Tournier B, Vyas SN, FitzGerald GA. Cyclooxygenase inhibitors and the antiplatelet effects of aspirin. N Engl J Med. 2001; 345:1809–1817.
  5. Advil® (ibuprofen) Product Information.[www.advil.com/products/advil/tablet_label.asp. ]
  6. Farkouh ME, Greenberg JD, Jeger RV, Ramanathan K, Verheugt FW, Chesebro JH, Kirshner H, Hochman JS, Lay CL, Ruland S, Mellein B, Matchaba PT, Fuster V, Abramson SB. Cardiovascular outcomes in high-risk patients with osteoarthritis treated with ibuprofen, naproxen, or lumiracoxib. Ann Rheum Dis.2007; 66:764–770.
  7. Catella-Lawson F, Reilly MP, Kapoor SC, Cucchiara AJ, DeMarco S, Tournier B, Vyas SN, FitzGerald GA. Cyclooxygenase inhibitors and the antiplatelet effects of aspirin. N Engl J Med. 2001; 345:1809–1817.
  8. Brune K, Hochberg MC, Schiff M, Oldenhof J, Schuller R, Zlotnick S. The platelet inhibitory effects of the combination of naproxen sodium or acetaminophen with low-dose aspirin [abstract] Arthritis Rheum.2007; 56(9):S359.
  9. Capone ML, Tacconelli S, Sciulli MG, Grana M, Ricciotti E, Minuz P, Di Gregorio P, Merciaro G, Patrono C, Patrignani P. Clinical pharmacology of platelet, monocyte, and vascular cyclooxygenase inhibition by naproxen and low-dose aspirin in healthy subjects. Circulation. 2004; 109:1468–1471. 
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