What is the best treatment approach for an elderly patient with moderate bilateral acromioclavicular (AC) and glenohumeral joint osteoarthritis?

Treatment of Elderly Patients with Moderate Bilateral AC and Glenohumeral Joint Osteoarthritis

Begin with a structured non-pharmacological foundation of exercise therapy and patient education, followed by acetaminophen as first-line pharmacological treatment, reserving topical NSAIDs for inadequate response and oral NSAIDs only when other options fail, with mandatory gastroprotection and cardiovascular risk assessment. 1

Initial Non-Pharmacological Interventions (Foundation of Treatment)

All elderly patients with shoulder osteoarthritis should receive exercise therapy as the cornerstone of treatment, combining both joint-specific strengthening and general aerobic conditioning. 2, 1

Exercise Prescription Specifics:

• Start with isometric strengthening exercises when joints are acutely inflamed or painful, as these produce low articular pressures and are well tolerated. 2

  • Perform contractions at 30% of maximal voluntary contraction initially, holding for 6 seconds
  • Progress gradually to 75% intensity as tolerated
  • Perform 5-7 repetitions, 3-5 times daily 2

• Progress to dynamic strengthening as pain permits, focusing on muscles supporting the shoulder girdle. 2

  • Muscles should not be exercised to fatigue
  • Exercise resistance must remain submaximal
  • Joint pain lasting >1 hour after exercise indicates excessive activity 2

• Incorporate aerobic exercise such as walking or aquatic therapy. 2

  • Aquatic exercise in warm water (86°F) is particularly beneficial, providing analgesia, reducing joint loading through buoyancy, and offering resistance for strengthening 2
  • Avoid high-impact activities, as rapid joint loading rates increase pain and potential damage 2

Patient Education:

• Provide both oral and written information to counter the misconception that osteoarthritis is inevitably progressive and untreatable. 1
• Emphasize activity pacing to avoid peaks and troughs of joint stress. 1

Weight Management:

• If the patient is overweight or obese, weight loss is essential even for upper extremity osteoarthritis, as it reduces systemic inflammation and improves overall function. 2, 1

Pharmacological Treatment Algorithm

First-Line: Acetaminophen

Acetaminophen (paracetamol) is the preferred first-line oral analgesic for elderly patients with osteoarthritis. 2, 1

• Dose: Up to 4000 mg/day in divided doses 2, 1
• Provides pain relief comparable to NSAIDs without gastrointestinal risks 2
• Monitor for hepatotoxicity, particularly in patients with liver disease or alcohol use 1

Second-Line: Topical NSAIDs

If acetaminophen provides inadequate relief, topical NSAIDs should be the next step before considering oral NSAIDs. 1

• Topical NSAIDs have fewer systemic side effects than oral formulations 1
• Particularly effective for superficial joints 3
• Apply to affected shoulder areas as directed

Third-Line: Oral NSAIDs (Use with Extreme Caution)

Oral NSAIDs should only be prescribed when topical options fail, and require comprehensive risk assessment first. 2, 1

Mandatory Pre-NSAID Risk Assessment:

Before prescribing any oral NSAID, assess three critical risk domains: 1, 4

1. Cardiovascular risk factors (hypertension, heart failure, coronary disease, stroke history) 1, 4
2. Gastrointestinal risk factors (prior ulcer, GI bleeding, age >65, concurrent anticoagulants/corticosteroids) 2, 4
3. Renal function (chronic kidney disease, volume depletion, concurrent ACE inhibitors/diuretics) 1, 4

NSAID Prescribing Protocol:

• Use the lowest effective dose for the shortest possible duration 4, 1
• For osteoarthritis: Ibuprofen 400-800 mg three to four times daily (maximum 3200 mg/day), though doses >400 mg may not provide additional benefit 4
• Mandatory co-prescription of proton pump inhibitor for gastroprotection in elderly patients 1
• Avoid in patients with aspirin-sensitive asthma due to cross-reactivity risk 4

Critical NSAID Monitoring:

• Monitor for GI symptoms (epigastric pain, dyspepsia, melena, hematemesis) 4
• Check hemoglobin/hematocrit if signs of anemia develop, as NSAIDs can cause occult GI bleeding 4
• Monitor renal function periodically, especially in elderly patients 4
• Assess cardiovascular symptoms (chest pain, shortness of breath, weakness, slurred speech) 4

Adjunctive Therapies

Thermal Modalities:

• Local heat or cold applications can provide temporary pain relief. 2, 1
• Apply before exercise or during pain flares 2

Assistive Devices:

• Consider adaptive equipment for activities of daily living to reduce shoulder stress. 5

What NOT to Use

Do not recommend glucosamine or chondroitin products, as they lack evidence of efficacy over placebo. 1, 6

Do not use electroacupuncture, as it is not supported by current evidence. 1

Follow-Up and Monitoring

Re-evaluate treatment effectiveness at 4 weeks. 2

• If pain is reduced and function improved, continue current regimen and monitor every 4-6 months 2
• If inadequate response, advance to next treatment tier 2
• Adjust treatment as disease course and patient needs change over time 1

Common Pitfalls to Avoid

• Never start with oral NSAIDs in elderly patients without exhausting safer options first 1
• Never prescribe NSAIDs without gastroprotection in patients >65 years 1
• Never ignore cardiovascular risk assessment before NSAID use, as elderly patients have elevated baseline risk 1, 4
• Never allow patients to combine OTC NSAIDs with prescribed NSAIDs, as this increases toxicity risk 2
• Never prescribe NSAIDs in patients with severe renal impairment or decompensated heart failure 4