Chapter 51. Osteoarthritis
BY is a 65-year-old man with confirmed osteoarthritis (OA). He has been pain-free on his current regimen of acetaminophen 650 mg every 6 hours for 2 years. Past medical history (PMH) is significant for gastrointestinal (GI) bleed 4 years ago and hypertension (HTN). He now presents to your clinic with pain in his left hip. BY’s medication regimen also consists of lisinopril 40 mg daily and hydrochlorothiazide 25 mg daily. What recommendation will you present to the physician?
a. Increase acetaminophen to 1000 mg every 4 hours, reinforce fitness program.
b. Add pantoprazole 40 mg daily to his regimen, reinforce fitness program.
c. Stop acetaminophen, begin ibuprofen 400 mg tid, reinforce fitness program.
d. Stop acetaminophen, begin Anaprox 250 mg bid, Protonix 40 mg daily, reinforce fitness program.
e. Add celecoxib 200 mg daily, reinforce fitness program.
Answer d is correct. Naproxen is a member of the nonselective nonsteroidal anti-inflammatory drug (NSAID) class. Increased cardiovascular disease may be higher in NSAIDs as a class. At this time, naproxen is the only nonselective drug studied that has a lower risk than ibuprofen or diclofenac. BY has a PMH of GI bleed, so a GI protective agent such as pantoprazole should be added to his NSAID regimen. Reinforcing muscle-strengthening and range-of-motion exercises should be part of every OA treatment.
Answer a is incorrect. The maximum dose for acetaminophen is 4000 mg daily. This answer gives a daily dose of 6000 mg daily and increases the patient’s risk for developing hepatotoxicity.
Answer b is incorrect. The addition of pantoprazole would provide some GI protection, but would not provide any more pain relief.
Answer c is incorrect. BY has HTN and is at high risk for cardiovascular disease. Though studies are not conclusive and all drugs in the nonselective NSAID class have not been studied, ibuprofen has shown some increased risk of myocardial infarction (MI), stroke, heart failure, and HTN
Answer e is incorrect. Studies have shown that cyclooxygenase (COX)-2 inhibitors have an increased risk of MI, stroke, heart failure, and HTN. Celecoxib would not be an appropriate choice as BY has hypertension and is at high CV risk.
DP is a 55-year-old man who has hypertension and a positive family history of early cardiovascular (CV) disease. His medications include aspirin 81 mg daily and metoprolol 25 mg bid. DP’s osteoarthritis is no longer controlled with acetaminophen 650 mg every 6 hours. The physician wants to begin DP on a regimen including an nonsteroidal anti-inflammatory (NSAID). Which treatment do you recommend?