What are the next steps for a middle-aged to elderly patient with osteoarthritis, experiencing fatigue and lightheadedness, who has been taking Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) long-term?

Immediate Evaluation for NSAID-Related Complications

This patient requires urgent assessment for gastrointestinal bleeding and anemia, as fatigue and lightheadedness in an elderly patient on chronic NSAIDs strongly suggests blood loss until proven otherwise. 1

Critical First Steps

Immediate Laboratory Workup

• Order complete blood count (CBC) with differential to assess for anemia 1
• Check hemoglobin, hematocrit, and mean corpuscular volume (MCV) to characterize any anemia present 1
• Obtain serum creatinine and estimated glomerular filtration rate (eGFR) to evaluate for NSAID-induced nephrotoxicity 1, 2
• Measure blood pressure to assess for hypertension or orthostatic changes 1
• Consider stool guaiac or fecal immunochemical test if GI bleeding is suspected 3

Physical Examination Priorities

• Assess for orthostatic vital signs (blood pressure and pulse supine and standing) to evaluate volume status 1
• Examine for pallor, tachycardia, and signs of heart failure (edema, jugular venous distension) 3, 1
• Palpate abdomen for tenderness, particularly epigastric pain suggesting peptic ulcer disease 3

Immediate NSAID Management

Discontinue Current NSAIDs

Stop all NSAIDs immediately until the cause of symptoms is identified and addressed. 1 Elderly patients are at extremely high risk for NSAID-related adverse events including gastrointestinal bleeding (23.5% of hospitalizations in older adults), renal insufficiency, and cardiovascular complications. 3, 1

Critical Pitfall to Avoid

Do not restart NSAIDs without first ruling out serious complications and implementing gastroprotection if NSAIDs are absolutely necessary. 1 The American Geriatrics Society recommends that NSAIDs should be avoided or used with extreme caution in older adults aged 70 years and above due to risks that outweigh benefits. 1

Transition to Safer Pain Management

First-Line Pharmacologic Option

Switch to acetaminophen 650-1000 mg every 6-8 hours (maximum 3000-4000 mg daily in elderly patients) as the preferred first-line agent. 3, 4 Acetaminophen provides pain relief comparable to NSAIDs without gastrointestinal, renal, or cardiovascular toxicity. 3

Second-Line Options if Acetaminophen Insufficient

Consider topical NSAIDs (diclofenac gel) for localized joint pain as they provide effective analgesia with minimal systemic absorption and significantly lower cardiovascular and gastrointestinal risks than oral formulations. 3, 2, 5

Duloxetine 30 mg daily for one week, then 60 mg daily if tolerated is recommended for chronic musculoskeletal pain in older adults, particularly when acetaminophen has failed. 2 This avoids cardiovascular and gastrointestinal risks while providing small to moderate pain improvements. 2

Third-Line Consideration

Tramadol 25 mg every 6 hours as needed can be considered only if acetaminophen, topical NSAIDs, and duloxetine are ineffective. 2 However, the American Academy of Orthopaedic Surgeons recommends against tramadol for osteoarthritis due to increased medication-related adverse effects with no consistent improvement. 4 Use extreme caution given fall and cognitive impairment risks in elderly patients. 4

Essential Non-Pharmacologic Interventions

Implement exercise therapy as a foundational treatment including strengthening, aerobic exercise, and tai chi, which should be individualized and progressively overloaded. 3 Regular moderate-level exercise reduces pain and morbidity without exacerbating osteoarthritis. 3

Recommend weight loss of 5.0-7.5% of body weight minimum if BMI ≥25 kg/m², as greater weight loss provides symptomatic benefits for hip and knee osteoarthritis. 3

Provide ongoing patient education that is patient-centered and includes information about osteoarthritis, management options, ergonomic principles, pacing, and assistive devices. 3

Consider physical therapy, thermal modalities (heat/cold), and assistive devices (walking aids) to reduce joint loading. 2, 4

If NSAIDs Must Be Restarted

Risk Minimization Strategy

Use the lowest effective dose for the shortest duration possible (not high doses for long periods). 3, 1

Prescribe a proton pump inhibitor or misoprostol for gastrointestinal protection in all elderly patients requiring NSAIDs. 3, 1

Prefer topical NSAIDs over oral for patients ≥75 years with localized osteoarthritis. 3

If oral NSAIDs are necessary, consider naproxen or low-dose celecoxib (200 mg/day) as they have lower cardiovascular risk profiles. 6

Mandatory Monitoring Requirements

Assess renal function (serum creatinine, eGFR) every 3-6 months or 1-2 weeks after starting any NSAID 2

Monitor blood pressure regularly 1

Assess for signs of heart failure, gastrointestinal symptoms, and drug-drug interactions at each visit 1

Evaluate pain scores and functional status periodically 2

Absolute Contraindications for NSAID Use

Do not prescribe NSAIDs if the patient has active peptic ulcer disease, chronic kidney disease, or heart failure. 1 These are absolute contraindications in older adults. 1