What would be an inappropriate therapy for a 90-year-old woman with bone-on-bone knee pain who cannot receive further injections?

Management of Bone-on-Bone Knee Pain in a 90-Year-Old Woman Unable to Receive Injections

Opioids (including tramadol) should NOT be used for this 90-year-old woman with bone-on-bone knee pain due to their poor safety profile and lack of consistent improvement in pain and function. 1

First-Line Treatments

Non-Pharmacological Approaches

• Physical therapy and exercise

  • Focus on strengthening exercises for the muscles around the knee
  • Low-impact activities such as water exercises or stationary cycling
  • Regular physical activity to maintain function 1

• Assistive devices

  • Walking stick or cane (used in the hand opposite to the affected knee)
  • Knee braces or supports for biomechanical joint pain or instability
  • Appropriate footwear with shock-absorbing insoles 1

• Weight management (if applicable)

  • Even modest weight loss can reduce knee pain and improve function 1

Topical Treatments

• Topical NSAIDs (e.g., diclofenac)

  • First-line pharmacological option for this age group
  • Provides localized pain relief with minimal systemic absorption
  • Significantly fewer gastrointestinal adverse events compared to oral NSAIDs 1
  • Particularly appropriate for elderly patients (≥75 years) 2

• Topical capsaicin

  • Can be effective for localized knee pain
  • Works by depleting substance P, reducing pain signals 1

Second-Line Treatments

Oral Medications

• Acetaminophen (paracetamol)

  • Up to 4g/day in divided doses
  • Safe option for elderly patients with comorbidities
  • May require regular dosing to maintain analgesic effect 1
  • Monitor for hepatic effects, especially with long-term use

• Oral NSAIDs with gastroprotection (use with caution)

  • Only if topical treatments and acetaminophen are ineffective
  • Use lowest effective dose for shortest possible time
  • Must be prescribed with proton pump inhibitor for gastroprotection
  • Naproxen may have better cardiovascular safety profile 1, 3
  • Caution: High risk of GI bleeding, cardiovascular events, and renal impairment in elderly patients 4, 3

• Duloxetine

  • Consider as alternative or adjunctive therapy if other options fail
  • May help with pain modulation through central mechanisms 1

Inappropriate Treatments to Avoid

1. Opioids (including tramadol)

   • Not recommended due to significant adverse effects
   • Risk of falls, confusion, constipation, and dependence
   • Black box warning for elderly patients 1, 5

2. Glucosamine and chondroitin supplements

   • Not recommended due to lack of evidence for efficacy 1

3. Electroacupuncture

   • Not recommended based on insufficient evidence 1

4. Arthroscopic lavage and debridement

   • Not recommended for osteoarthritis without clear mechanical locking 1

5. Intra-articular hyaluronic acid injections

   • Inconsistent evidence for benefit
   • Not routinely recommended 1

Special Considerations for Elderly Patients

• Risk assessment: Consider comorbidities (cardiovascular, renal, hepatic function)
• Polypharmacy: Review all medications for potential interactions
• Monitoring: Regular follow-up to assess efficacy and adverse effects
• Dose adjustment: Start with lower doses and titrate slowly

Treatment Algorithm

1. Start with non-pharmacological approaches (assistive devices, physical therapy)
2. Add topical NSAIDs or capsaicin for localized pain
3. If inadequate relief, add acetaminophen (up to 4g/day)
4. For persistent pain, consider duloxetine as adjunctive therapy
5. Use oral NSAIDs with gastroprotection only if absolutely necessary and with close monitoring
6. Avoid opioids, including tramadol

Given the patient's advanced age and bone-on-bone arthritis, the focus should be on improving function and quality of life while minimizing medication-related risks. The combination of non-pharmacological approaches with targeted topical treatments offers the safest and most effective strategy for managing her knee pain.