What is the recommended treatment approach for an adult or geriatric patient with chronic pain, likely due to osteoarthritis, considering the use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

NSAIDs for Chronic Pain in Adults and Geriatric Patients

NSAIDs should not be first-line therapy for chronic pain in older adults—acetaminophen (up to 3000 mg daily in elderly) is the preferred initial pharmacologic treatment, with topical NSAIDs as the next step before considering oral NSAIDs, which require mandatory gastroprotection with a proton pump inhibitor or misoprostol. 1

Initial Pharmacologic Approach

Start with acetaminophen 650-1000 mg every 6-8 hours on a regular schedule (not as-needed dosing), with a maximum of 3000 mg daily in elderly patients to minimize hepatotoxicity risk. 1, 2 Regular dosing throughout the day provides superior sustained pain control compared to PRN administration. 1

• If acetaminophen alone is insufficient after an adequate trial, add topical NSAIDs (such as diclofenac gel applied 4 times daily) to the affected joint before escalating to oral NSAIDs. 1, 3
• Topical NSAIDs provide efficacy comparable to oral NSAIDs for localized joint pain (hands, knees) with minimal systemic absorption and significantly lower risk of gastrointestinal, renal, and cardiovascular adverse events. 3, 1

When Oral NSAIDs Are Necessary

If topical therapy fails and oral NSAIDs are required, you must co-prescribe a proton pump inhibitor or misoprostol for gastrointestinal protection—this is non-negotiable. 4, 1

Critical Safety Requirements Before Prescribing Oral NSAIDs:

• Assess renal function: NSAIDs are contraindicated or require extreme caution in renal insufficiency. 1, 4
• Evaluate cardiovascular risk: NSAIDs increase risk of myocardial infarction, stroke, and heart failure, particularly with longer use. 5, 6
• Screen for GI risk factors: History of ulcers, concurrent anticoagulants or corticosteroids, older age, and alcohol use all substantially increase bleeding risk. 5, 4
• Never prescribe NSAIDs immediately before or after coronary artery bypass graft surgery. 5

NSAID Selection and Monitoring:

• Use the lowest effective dose for the shortest duration possible. 5, 4
• Never combine two NSAIDs or use an NSAID with a COX-2 inhibitor simultaneously. 4
• If the patient takes aspirin for cardioprophylaxis, avoid ibuprofen as it interferes with aspirin's antiplatelet effect. 4
• Routinely monitor for gastrointestinal toxicity, renal function, blood pressure, heart failure exacerbation, and drug-drug interactions. 4

Non-Pharmacologic Core Treatments (Mandatory, Not Optional)

Exercise therapy—including joint-specific strengthening and general aerobic conditioning—must accompany any pharmacologic management and should be implemented before escalating to oral NSAIDs. 1, 4 Randomized controlled trials demonstrate that regular moderate exercise reduces pain and improves function without exacerbating osteoarthritis. 4

Additional essential interventions include:

• Weight loss if overweight or obese (sustained weight loss significantly benefits pain and function). 1, 2
• Local heat or cold applications for temporary symptom relief. 1, 2
• Assistive devices and shock-absorbing footwear to reduce joint loading. 1

Alternative Options When NSAIDs Fail or Are Contraindicated

• Intra-articular corticosteroid injections (such as triamcinolone hexacetonide) provide effective short-term relief for acute pain flares, especially with joint effusion. 4, 1
• Topical capsaicin or menthol may be considered for regional pain syndromes. 4
• Opioid therapy should be reserved for patients with moderate to severe pain, pain-related functional impairment, or diminished quality of life when safer alternatives have failed. 4, 1

What NOT to Do: Critical Pitfalls

• Never start with oral NSAIDs as first-line therapy in elderly patients—the age-related physiological changes dramatically worsen the side-effect profile. 7, 8
• Never prescribe oral NSAIDs without gastroprotection—gastrointestinal bleeding is a leading cause of hospitalization and may increase risk of death more than 4-fold in elderly patients. 7, 1
• Never exceed maximum acetaminophen doses when using fixed-dose opioid combination agents (such as hydrocodone/acetaminophen). 4
• Do not prescribe glucosamine or chondroitin—evidence does not support their use despite their popularity. 1
• Avoid long-term systemic corticosteroids for osteoarthritis, as it should not be considered an inflammatory disorder. 4

Special Considerations for High-Risk Patients

Elderly patients with recent falls, cognitive impairment, congestive heart failure, hypertension, hepatic disease, or renal disease face substantially higher risks with NSAIDs and may be better candidates for acetaminophen plus topical therapies exclusively. 1, 2, 6 In these populations, the risk-benefit calculation strongly favors avoiding oral NSAIDs entirely.