What are examples of non-controlled substance pain medications that are safe for elderly patients and those at increased risk of bleeding, who cannot take nonsteroidal anti-inflammatory drugs (NSAIDs) due to gastrointestinal (GI) bleeding risk?

From the Guidelines

For elderly patients who cannot take nonsteroidal anti-inflammatory drugs (NSAIDs) due to gastrointestinal (GI) bleeding risk, acetaminophen is the safest first-line option for pain relief, with a recommended dosage not exceeding 4 g per day, as suggested by the study published in The Journal of the American Academy of Orthopaedic Surgeons 1. The use of acetaminophen is supported by its mechanism of action, which reduces pain signals in the central nervous system without affecting platelets or the gastrointestinal lining, making it a safer alternative to NSAIDs for patients with bleeding concerns. Additional options for pain relief in these patients include:

• Topical NSAIDs, which have been shown to be effective and safe for pain relief, with a good safety record, as reported in the study published in Annals of the Rheumatic Diseases 1.
• Topical agents such as capsaicin, menthol, or camphor, which work locally without systemic effects and are well-tolerated by patients.
• Non-medication approaches, including physical therapy, heat or cold therapy, and gentle exercise, which can help alleviate pain and improve quality of life. It is essential to note that the efficacy and safety of these options may vary depending on individual patient factors, and the choice of treatment should be tailored to each patient's specific needs and medical history. The study published in Annals of the Rheumatic Diseases 1 also highlights the importance of considering the clinical predictors of response to pharmacological and non-pharmacological interventions, as well as the need to establish a set of recommendations for uniform and full reporting of clinical trials in knee OA. Overall, the goal of treatment should be to provide effective pain relief while minimizing the risk of adverse effects, particularly in elderly patients who are at increased risk of bleeding and other complications. The use of acetaminophen as a first-line option for pain relief in elderly patients who cannot take NSAIDs due to GI bleeding risk is supported by the available evidence, and healthcare providers should consider this option when developing treatment plans for these patients.

From the FDA Drug Label

ACTIVE INGREDIENT (IN EACH CAPLET) Acetaminophen USP, 650 mg Active Ingredient Purpose Capsaicin 0.035% External Analgesic PRINCIPAL DISPLAY PANEL - 77 g Bottle Carton TopCare® health COMPARE TO ICY HOT® ACTIVE INGREDIENTS* MAXIMUM STRENGTH LIDOCAINE Cold & Hot Pain Relieving Lidocaine Cream 4% Lidocaine • 1% Menthol LIDOCAINE 4% / TOPICAL ANALGESIC MENTHOL 1% / TOPICAL ANALGESIC Helps to Numb Away Pain Non-Greasy Maximum Strength External Analgesic with 4% Lidocaine Examples of non-controlled substance pain medications that are safe for elderly patients and those at increased risk of bleeding, who cannot take nonsteroidal anti-inflammatory drugs (NSAIDs) due to gastrointestinal (GI) bleeding risk are:

• Acetaminophen 2
• Lidocaine (topical) 3
• Capsaicin (topical) 4 These options are non-controlled substances and can be used as alternatives to NSAIDs for pain management in patients at risk of GI bleeding.

From the Research

Non-Controlled Substance Pain Medications for Elderly Patients

• Paracetamol (acetaminophen) is a suitable first-choice analgesic for mild to moderate acute pain in adults with liver, kidney, or cardiovascular disease, gastrointestinal disorders, asthma, or who are older 5
• Paracetamol is generally well-tolerated at recommended doses (≤4 g/day) in healthy adults and may be preferable to non-steroidal anti-inflammatory drugs (NSAIDs) that are associated with undesirable gastrointestinal, renal, and cardiovascular effects 5
• No evidence supports routine dose reduction for older people, but dosing for adults who are older and/or have decompensated cirrhosis, advanced kidney failure, or analgesic-induced asthma that is known to be cross-sensitive to paracetamol, should be individualized in consultation with their physician 5

Risks Associated with NSAIDs in Elderly Patients

• Gastrointestinal (GI) bleeding is an unwanted side effect common to all chemical types of NSAIDs, particularly in elderly people 6
• Family history of GI bleeding, history of peptic ulcers, history of cardiovascular and cerebrovascular disease, diabetes mellitus, antiplatelet drugs, Helicobacter pylori infection, hypocholesterolemia, and NSAIDs used for 0.5 to 3 months are independent risk factors for GI bleeding in people over 60 years old 6
• Physiological changes of aging worsen the side-effect profile of NSAIDs in the elderly, leading to a much greater risk for adverse outcomes when NSAIDs are used in the elderly patient 7

Alternative Pain Management Options

• Paracetamol (acetaminophen) is a suitable alternative to NSAIDs for mild to moderate acute pain in elderly patients 5
• Other non-controlled substance pain medications may be considered, but the evidence is limited, and individualized treatment plans should be developed in consultation with a physician 8, 9