What is the diagnosis and treatment plan for an 89-year-old female with bilateral knee pain, who is non-ambulatory and requires 2-person assistance from a chair, and is currently using Voltaren (Diclofenac)?

From the Guidelines

For an 89-year-old female with bilateral knee pain who is non-ambulatory and requires two-person assistance from a chair, I strongly recommend adding acetaminophen to her current treatment regimen, as it has been shown to be effective in reducing pain in knee osteoarthritis with minimal side effects, especially in the elderly 1. The patient is currently using Voltaren, which is a type of NSAID, and while it can be effective, the addition of acetaminophen can provide further pain relief without significantly increasing the risk of adverse effects. According to the EULAR recommendations for the management of knee osteoarthritis, paracetamol (acetaminophen) is effective in the treatment of knee OA and can be used safely over the long term, making it a suitable option for this patient 1. Some key points to consider in the management of this patient's knee pain include:

• Continuing the use of topical Voltaren gel (diclofenac sodium 1%) applied to both knees 3-4 times daily, as it can provide localized pain relief with minimal systemic side effects.
• Adding acetaminophen 650-1000mg every 6 hours as needed for pain, not exceeding 3000mg daily due to her advanced age, to provide additional pain relief.
• Considering non-pharmacological interventions such as physical therapy, focusing on gentle range of motion exercises and strengthening while seated, to help maintain joint function and prevent further deterioration.
• Using a cushioned wheelchair cushion to reduce pressure on her knees when seated, which can help alleviate pain and discomfort.
• If pain persists, considering the addition of low-dose tramadol 25-50mg every 6 hours as needed, but with caution due to the risk of falls in elderly patients. The American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee also support the use of acetaminophen as a first-line treatment for knee OA, especially in patients with no contraindications or comorbidities that may increase the risk of adverse effects 1. Overall, a multimodal approach that includes pharmacological and non-pharmacological interventions can help address this patient's knee pain and improve her quality of life.

From the FDA Drug Label

Avoid Concomitant Use of NSAIDs Inform patients that the concomitant use of diclofenac potassium tablets with other NSAIDs or salicylates (e.g., diflunisal, salsalate) is not recommended due to the increased risk of gastrointestinal toxicity, and little or no increase in efficacy Use of NSAIDs and Low-Dose Aspirin Inform patients not to use low-dose aspirin concomitantly with a diclofenac potassium tablets until they talk to their healthcare provider

The patient is using Voltaren, which is another name for diclofenac. The drug label warns against concomitant use of NSAIDs, which includes diclofenac. Since Voltaren is already an NSAID, and the patient is 89 years old, it is recommended to exercise caution due to the increased risk of gastrointestinal toxicity. It is advised to consult the healthcare provider before continuing the use of Voltaren. 2

From the Research

Mobility and Pain Management

• The patient's bilateral knee pain and limited mobility can have significant effects on her health, independence, and quality of life 3.
• Mobility loss in older adults is associated with poor outcomes, including loss of muscle mass and strength, long hospital stays, falls, declines in activities of daily living, decline in community mobility and social participation, and nursing home placement 3.
• The patient's current use of Voltaren (a topical NSAID) may be beneficial for managing her osteoarthritis-related pain, as topical NSAIDs have been shown to be effective and safe for patients with mild to moderate OA pain 4, 5.

Considerations for Mobilization

• Mobilization can be an important aspect of managing critically ill patients, including those with limited mobility like the patient in question 6.
• However, mobilization should be approached with caution, taking into account the patient's medical background, cardiovascular and respiratory reserve, and hematological considerations, as well as extrinsic factors such as patient attachments, environment, and staffing 6.
• A comprehensive assessment of the patient's safety and mobility status is necessary to determine the best approach for mobilization and pain management 3, 7.

Pharmacological Treatment Options

• The patient's current use of Voltaren may be effective for managing her osteoarthritis-related pain, but other pharmacological treatment options may also be considered, such as oral NSAIDs, duloxetine, or intraarticular injections with glucocorticoids 4.
• However, the use of these treatment options should be carefully considered, taking into account the patient's comorbidities and potential side effects 4, 5.