What is the appropriate management plan for an 81-year-old male patient with neuropathy, hypertension, hyperlipidemia, aortic aneurysm, and a history of bladder cancer, who is on long-term aspirin therapy?

Management Plan for 81-Year-Old Male with Neuropathy and Multiple Comorbidities

The most appropriate management for this 81-year-old male with neuropathy includes gabapentin starting at 300 mg/day and titrating to 900 mg/day, discontinuing ibuprofen due to cardiovascular risk, continuing aspirin for secondary prevention, and optimizing blood pressure control with beta blockers as the preferred agent due to his aortic aneurysm.

Assessment of Neuropathic Pain

• Neuropathic pain presents with characteristic symptoms including:

  • Sensory "plus" features: acral pain, paraesthesia, dysaesthesia, allodynia, hyperalgesia
  • Sensory "minus" symptoms: numbness in hands and feet, impaired perception of light touch, vibration, pin prick, and proprioception
  • "Glove and stocking" distribution of symptoms 1

• Early detection and assessment are critical for adequate management

  • Physical examination should include assessment of sensory function, deep tendon reflexes, and motor strength
  • Consider neurophysiological examination (EMG with nerve conduction studies) if symptoms are asymmetric or unclear 1

Medication Management

Neuropathy Treatment

1. First-line therapy: Gabapentin

   • Start at 300 mg/day on day 1
   • Increase to 600 mg/day on day 2
   • Target dose of 900 mg/day by day 3
   • May titrate up to 1800 mg/day for greater efficacy if needed
   • Maximum dose of 3600 mg/day in some patients 2
   • Dose adjustment required for renal impairment 3

2. Alternative options if gabapentin is not tolerated:

   • Pregabalin: Starting at lower doses with careful titration due to age and potential renal impairment 4
   • Duloxetine: Consider if comorbid depression is present, but monitor for side effects including nausea, dry mouth, and somnolence 5

Management of Current Medications

1. Discontinue ibuprofen

   • NSAIDs increase risk of cardiovascular events, with ibuprofen having a relative risk of 1.51 (95% CI: 0.96-2.37) 6
   • Particularly concerning given patient's history of hypertension, aortic aneurysm, and aspirin use
   • Consider acetaminophen (≤3g/day) as an alternative for pain management 6

2. Continue aspirin therapy

   • Maintain low-dose aspirin (75-162 mg/day) as secondary prevention for cardiovascular disease 1
   • Aspirin has shown efficacy in reducing cardiovascular morbidity and mortality in high-risk patients 1
   • No clear evidence that aspirin negatively impacts aortic aneurysm outcomes 7

3. Optimize antihypertensive therapy

   • Beta blockers are recommended as preferred agents for patients with thoracic aortic disease 1
   • Target BP <140/90 mmHg, but consider "as low as reasonably achievable" principle given patient's age 1
   • Consider frailty assessment to guide blood pressure targets 1
   • Test for orthostatic hypotension before intensifying therapy 1

Cardiovascular Risk Management

1. Statin therapy

   • Continue rosuvastatin for secondary prevention of cardiovascular events 1
   • Target LDL-C <70 mg/dL for very high-risk patients with overt CVD 1
   • Consider benefit-risk assessment in context of age and multiple comorbidities 1

2. Aortic aneurysm monitoring

   • Regular imaging surveillance of aortic aneurysm
   • Monitor for symptoms of aneurysm expansion (back or abdominal pain)
   • Maintain blood pressure control to reduce risk of dissection 1

Special Considerations for Geriatric Patient

• When initiating therapy in patients ≥85 years or with moderate-to-severe frailty:

  • Start with lower doses and titrate slowly
  • Monitor for adverse effects more frequently
  • Consider deprescribing medications if blood pressure drops with progressing frailty 1

• Polypharmacy management:

  • Regularly review medication list for potential interactions and unnecessary medications
  • Consider deprescribing herbal supplements and vitamins that add complexity without evidence of benefit 1

Follow-up Plan

• Monitor blood pressure within 1-2 weeks of medication changes
• Assess response to neuropathy treatment after 2-4 weeks
• Regular surveillance of aortic aneurysm (frequency based on size and location)
• Annual assessment of cardiovascular risk factors and medication efficacy
• Regular kidney function monitoring due to age and medication regimen