What is the recommended approach for managing osteoarthritis pain in the elderly?

Osteoarthritis Pain Management in Elderly

Begin with exercise therapy, weight loss if overweight, and patient education as core non-pharmacological treatments, then initiate paracetamol (acetaminophen) as first-line pharmacological therapy, followed by topical NSAIDs for knee/hand OA before considering oral NSAIDs with mandatory proton pump inhibitor co-prescription, given the elderly population's heightened risk for gastrointestinal, cardiovascular, and renal toxicity. 1

Core Non-Pharmacological Treatments (Mandatory for All Patients)

• Exercise therapy including local muscle strengthening and general aerobic fitness training must be provided to all elderly patients with symptomatic osteoarthritis, as this improves both pain and function 1, 2
• Weight loss interventions are essential if the patient is overweight or obese, as this reduces mechanical stress on weight-bearing joints 1, 2
• Patient education with both oral and written information to counter the misconception that osteoarthritis is inevitably progressive and untreatable 1, 2

Pharmacological Treatment Algorithm

Step 1: First-Line Medication

• Paracetamol (acetaminophen) should be offered initially for pain relief, with regular dosing as needed up to 4000 mg/day 1, 2
• Topical NSAIDs should be considered before oral NSAIDs, particularly for knee and hand osteoarthritis, as they have fewer systemic side effects 1, 2
• Topical capsaicin can be considered as an additional topical option 1

Step 2: Second-Line Medication (If First-Line Insufficient)

• Oral NSAIDs or COX-2 inhibitors should be prescribed at the lowest effective dose for the shortest possible period 1, 2
• Mandatory co-prescription of proton pump inhibitor with any oral NSAID or COX-2 inhibitor, choosing the one with lowest acquisition cost 1
• The first choice should be either a COX-2 inhibitor (other than etoricoxib 60 mg) or a standard NSAID 1

Step 3: Third-Line Medication (If Second-Line Insufficient)

• Add opioid analgesics or substitute with oral NSAID/COX-2 inhibitor in addition to paracetamol 1, 2
• Intra-articular corticosteroid injections should be considered for moderate to severe pain 1, 2

Critical Safety Considerations in Elderly Patients

All oral NSAIDs and COX-2 inhibitors have similar analgesic efficacy but vary significantly in gastrointestinal, liver, and cardiorenal toxicity. 1

• Assess cardiovascular risk factors before prescribing NSAIDs, as elderly patients have increased baseline cardiovascular risk 1, 3
• Assess gastrointestinal risk factors including history of peptic ulcer disease, GI bleeding, or concurrent anticoagulant/antiplatelet use 1, 3
• Assess renal function before initiating NSAIDs, as elderly patients have age-related decline in renal function 1, 3
• Monitor ongoing risk factors with periodic reassessment during NSAID therapy 1

Special Consideration for Aspirin Users

• If the patient requires low-dose aspirin, consider other analgesics (paracetamol, topical NSAIDs, opioids) before adding an oral NSAID or COX-2 inhibitor 1
• If NSAID is necessary in aspirin users, must co-prescribe proton pump inhibitor 1

Adjunct Non-Pharmacological Treatments

• Self-management strategies emphasizing exercise, weight loss, appropriate footwear with shock-absorbing properties, and activity pacing to avoid peaks and troughs 1, 2
• Local heat or cold applications for temporary pain relief 1, 2
• Transcutaneous electrical nerve stimulation (TENS) can be considered 1, 2
• Manual therapy (manipulation and stretching) particularly for hip osteoarthritis 1, 2
• Bracing, joint supports, or insoles for patients with biomechanical joint pain or instability 1, 2
• Assistive devices such as walking sticks for those with specific problems in activities of daily living 1, 2

Common Pitfalls and What NOT to Use

• Do NOT recommend glucosamine or chondroitin products, as they are not supported by current evidence 1, 2
• Do NOT use electroacupuncture, as it should not be used based on available evidence 1, 2
• Avoid polypharmacy interactions in elderly patients who are typically on multiple medications 3, 4

Monitoring and Follow-Up

• Provide periodic review tailored to individual needs, as disease course and patient requirements change over time 1, 2
• Assess treatment effectiveness regularly and adjust therapy accordingly 1, 2
• Evaluate impact on function, quality of life, occupation, mood, relationships, and leisure activities at each visit 1