What is the cause of bilateral knee pain in an 89-year-old patient using Voltaren (Diclofenac)?

From the Guidelines

For an 89-year-old with bilateral knee pain using Voltaren (diclofenac), I strongly recommend continuing the topical Voltaren gel as directed and adding acetaminophen (Tylenol) up to 3000mg daily in divided doses for additional pain relief, as this approach is supported by the most recent and highest quality evidence 1.

Key Considerations

• The patient's advanced age increases the risk of gastrointestinal bleeding, kidney problems, and cardiovascular events associated with oral NSAIDs, making topical Voltaren a safer option.
• Acetaminophen is recommended as the first-line oral analgesic for knee osteoarthritis, with a daily dose of up to 3000mg in divided doses 1.
• Non-pharmacological treatments such as knee braces, compression sleeves, gentle exercises, heat therapy, and cold packs can also help manage pain and improve function.

Treatment Approach

• Continue topical Voltaren gel as directed, typically applying it to each painful knee 3-4 times daily.
• Add acetaminophen (Tylenol) up to 3000mg daily in divided doses for additional pain relief.
• Consider using a knee brace or compression sleeve during activities for stability.
• Try gentle, non-weight bearing exercises like seated leg raises and water therapy to maintain strength without stressing the joints.
• Use heat therapy before activity and cold packs after to help manage pain.

Further Evaluation

If pain persists despite these measures, consult your doctor about physical therapy referral or possibly corticosteroid injections for more targeted relief, as supported by recent guidelines 1.

From the FDA Drug Label

14 CLINICAL STUDIES 14. 1 Study in Osteoarthritis of the Knee

Diclofenac sodium topical solution The use of diclofenac sodium topical solution for the treatment of pain of osteoarthritis of the knee was evaluated in a single double-blind controlled trial conducted in the US, involving patients treated with diclofenac sodium topical solution at a dose of 2 pumps twice a day for 4 weeks Diclofenac sodium topical solution was compared to topical vehicle, applied directly to the study knee. In this trial, patients treated with diclofenac sodium topical solution experienced a greater reduction in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale compared to patients treated with vehicle Numerical results of the WOMAC pain subscale are summarized in Table 4. Table 4: Change in Treatment Outcomes after 4 Weeks of Treatment with Diclofenac Sodium Topical Solution

• WOMAC pain subscale is based on the sum of pain scores for five items using a 5-point Likert scale Efficacy Variable Treatment Diclofenac Sodium Topical Solution N=130 Vehicle Control N=129 WOMAC Pain Subscale * Baseline Mean Change from Baseline 12.4 -4.5 `12.6 -3.6

The patient is using Voltaren, which is another name for diclofenac. According to the study, diclofenac sodium topical solution is effective in reducing pain associated with osteoarthritis of the knee. The study shows that patients treated with diclofenac sodium topical solution experienced a greater reduction in WOMAC pain subscale compared to patients treated with vehicle.

• Key points:
  • Diclofenac sodium topical solution is effective in reducing pain associated with osteoarthritis of the knee.
  • The patient's use of Voltaren (another name for diclofenac) may be beneficial for their bilateral knee pain. 2

From the Research

Diagnosis and Treatment of Bilateral Knee Pain

The patient's condition of bilateral knee pain can be diagnosed and treated based on the provided evidence.

• The patient is 89 years old and using Voltaren, which is a nonsteroidal anti-inflammatory drug (NSAID) 3.
• Knee osteoarthritis is a common disabling condition that affects more than one-third of persons older than 65 years, and exercise, weight loss, physical therapy, and the use of NSAIDs can decrease pain and improve function 3.
• The first-line management of osteoarthritis comprises exercise therapy, weight loss, education, and self-management programs to empower patients to better manage their condition 4.
• Intra-articular NSAIDs may be an alternative therapy to minimize systemic side effects while maintaining efficacy, and single doses of IA NSAIDs appear safe and efficacious across animals and humans 5.
• Topical capsaicin may represent an effective and safe alternative for pain management in osteoarthritis, with a good safety profile and efficacy in reducing osteoarthritis pain 6.

Treatment Options

Treatment options for the patient's bilateral knee pain may include:

• Continuing the use of Voltaren, as it is a NSAID that can help decrease pain and improve function 3.
• Considering alternative therapies such as intra-articular NSAIDs or topical capsaicin, which may have a better safety profile and efficacy 5, 6.
• Implementing exercise therapy, weight loss, and education as part of a self-management program to empower the patient to better manage their condition 4.
• Referring the patient to a specialist for further evaluation and treatment if the condition does not improve with conservative management 4, 7.