What is the most appropriate oral therapy for an 81-year-old female with osteoarthritis, coronary artery disease (CAD), gastroesophageal reflux disease (GERD), and a recent non-ST-segment myocardial infarction (MI)?

Celecoxib 100 mg Twice Daily is the Most Appropriate Oral Therapy for Osteoarthritis in an Elderly Patient with CAD, GERD, and Recent MI

Based on the PRECISION trial findings, celecoxib 100 mg twice daily is the most appropriate oral therapy for this 81-year-old female with osteoarthritis who has coronary artery disease, GERD, and a recent non-ST-segment myocardial infarction.

Rationale for Recommendation

Cardiovascular Safety Considerations

This patient has multiple high-risk cardiovascular factors:

• Advanced age (81 years)
• Known coronary artery disease
• Recent non-ST-segment myocardial infarction (4 months ago)

The PRECISION trial demonstrated that celecoxib 100 mg twice daily was non-inferior to naproxen and ibuprofen for cardiovascular safety, specifically for the composite endpoint of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke 1. This is particularly important for this patient with recent MI and established CAD.

Gastrointestinal Safety Profile

The patient also has GERD, making gastrointestinal safety a priority:

• Celecoxib has a more favorable upper GI safety profile compared to traditional NSAIDs like naproxen and ibuprofen
• The risk of GI bleeding, ulceration, and perforation is lower with celecoxib compared to non-selective NSAIDs 1

Analysis of Alternative Options

1. Naproxen 500 mg twice daily:

   • While naproxen may have a relatively favorable cardiovascular profile among non-selective NSAIDs, it carries a higher risk of GI complications compared to celecoxib 2
   • Problematic for a patient with GERD and advanced age

2. Ibuprofen 800 mg three times daily:

   • Associated with increased risk of GI complications 2
   • The high dose and frequency increase both GI and CV risks
   • Potential drug interactions with aspirin that may be part of the patient's post-MI regimen

3. Aspirin 650 mg three times daily:

   • High dose aspirin carries significant GI bleeding risk
   • Not recommended as primary analgesic for osteoarthritis
   • May already be on low-dose aspirin for CAD/post-MI

Dosing Considerations

The recommended dose of celecoxib for osteoarthritis is 100 mg twice daily 1, which aligns with the dose studied in the PRECISION trial that demonstrated cardiovascular safety. This is the appropriate dose for this elderly patient with multiple comorbidities.

Important Precautions

• Monitor for signs of cardiovascular events, as the patient is post-MI
• Consider concomitant proton pump inhibitor therapy given the patient's GERD and age
• Use the lowest effective dose for the shortest duration possible
• Regular follow-up to assess efficacy and monitor for adverse effects
• Avoid use with aspirin if possible, as this combination increases GI risk

Conclusion

For this 81-year-old female with osteoarthritis, coronary artery disease, GERD, and recent MI, celecoxib 100 mg twice daily offers the best balance of efficacy and safety based on the PRECISION trial findings. The other options (naproxen, ibuprofen, and high-dose aspirin) carry greater risks for this particular patient's comorbidity profile.