What is the appropriate management for an elderly hypertensive woman with controlled blood pressure, on Altraday (aceclofenac‑rabeprazole) once daily for grade II knee osteoarthritis for four years, now presenting with worsening knee pain, neuropathic pain radiating to the ankle, and mild‑moderate swelling of the lower leg to the toes?

Management of Worsening Osteoarthritis with Neuropathic Pain and Limb Swelling in a Hypertensive Patient

Stop Altraday (aceclofenac) immediately, as NSAIDs are causing both the worsening hypertension and the unilateral limb edema, and switch to acetaminophen up to 4 grams daily as first-line analgesic therapy for osteoarthritis pain. 1

Immediate Medication Changes

Discontinue the NSAID

• NSAIDs like aceclofenac antagonize antihypertensive therapy and cause sodium/water retention, leading to edema and elevated blood pressure, particularly in elderly patients. 1, 2, 3
• The unilateral limb swelling from knee to toes is most likely NSAID-induced peripheral edema, which occurs through prostaglandin inhibition causing renal sodium retention. 2, 4
• After 4 years of continuous NSAID use, this patient is at high risk for NSAID-induced renal impairment, which manifests as edema, worsening hypertension, and potential chronic kidney disease. 2, 5
• NSAIDs blunt the effectiveness of most antihypertensive agents (except calcium channel blockers), making blood pressure control difficult in elderly patients. 3, 4, 5, 6

Replace with Acetaminophen

• Acetaminophen up to 4 grams daily is the preferred first-line pharmacologic treatment for mild to moderate osteoarthritis pain in elderly patients. 1
• Acetaminophen provides comparable pain relief to NSAIDs for osteoarthritis without the cardiovascular, renal, or gastrointestinal toxicity. 1
• Start acetaminophen 1000 mg three times daily (total 3 grams/day), which can be increased to 1000 mg four times daily if needed. 1

Address the Neuropathic Pain Component

Add Neuropathic Pain Medication

• The nerve pain from knee to ankle represents neuropathic pain, which requires different pharmacologic treatment than nociceptive osteoarthritis pain. 1
• Start gabapentin 100-300 mg at bedtime, titrating slowly over weeks to 300 mg three times daily, as this is first-line therapy for neuropathic pain in elderly patients. 1
• Alternative options include pregabalin 75 mg twice daily or duloxetine 30-60 mg daily, though gabapentin has the best safety profile in elderly hypertensive patients. 1
• Neuropathic pain improvement begins weeks after initiating treatment, so set appropriate expectations with the patient. 1
• Avoid tricyclic antidepressants (amitriptyline, nortriptyline) as first-line in this elderly patient due to increased fall risk and orthostatic hypotension. 1

Optimize Hypertension Management

Adjust Antihypertensive Regimen

• Once the NSAID is stopped, reassess blood pressure control within 2-4 weeks, as NSAID discontinuation alone may restore adequate blood pressure control. 1
• If blood pressure remains >130/80 mmHg after stopping the NSAID, add amlodipine 5 mg daily, as calcium channel blockers are the only antihypertensive class whose efficacy is NOT blunted by NSAIDs and are preferred in elderly patients. 7, 3, 4, 5
• The European Society of Cardiology specifically recommends calcium channel blockers as first-line therapy for elderly hypertensive patients with comorbidities. 7
• Target blood pressure <140/90 mmHg for this elderly patient with multiple comorbidities, accepting higher targets if symptomatic orthostatic hypotension develops. 1, 7

Evaluate and Manage the Limb Swelling

Rule Out Serious Causes

• Obtain urgent venous duplex ultrasound of the affected limb to exclude deep vein thrombosis, as unilateral leg swelling always requires DVT exclusion. [General Medicine Knowledge]
• Check serum creatinine, BUN, and urinalysis to assess for NSAID-induced acute kidney injury or chronic kidney disease. 2
• Measure serum albumin to exclude hypoalbuminemia as a cause of edema. [General Medicine Knowledge]

Expected Course After NSAID Discontinuation

• NSAID-induced edema typically resolves within 1-2 weeks of drug discontinuation as sodium and water are excreted. 2
• If edema persists beyond 2 weeks after stopping aceclofenac, consider adding a low-dose thiazide diuretic (hydrochlorothiazide 12.5 mg daily) or loop diuretic if renal function is impaired. 7

Non-Pharmacologic Interventions for Osteoarthritis

Implement Evidence-Based Physical Therapy

• Prescribe structured exercise therapy focusing on quadriceps strengthening and range-of-motion exercises, as exercise provides significant pain relief and functional improvement in knee osteoarthritis. 1
• Refer to physical therapy for supervised exercise program 2-3 times weekly for 8-12 weeks. 1
• Recommend daily walking 30 minutes on most days, as aerobic exercise reduces both osteoarthritis pain and blood pressure. 1

Consider Topical Therapies

• Add topical diclofenac gel or topical NSAIDs to the affected knee, as topical NSAIDs provide localized pain relief without systemic absorption and are specifically recommended for elderly patients with osteoarthritis. 1
• Topical NSAIDs are safe in elderly patients and do not cause the systemic cardiovascular or renal effects of oral NSAIDs. 1
• Alternative topical agents include capsaicin cream 0.025-0.075% applied 3-4 times daily, though it requires 2-4 weeks for maximal effect. 1

Intra-articular Therapy for Refractory Pain

Consider Joint Injections

• If pain remains severe despite acetaminophen and topical therapy, refer for intra-articular corticosteroid injection (triamcinolone 40 mg), which provides 4-12 weeks of pain relief in knee osteoarthritis. 1
• Intra-articular hyaluronic acid injections are an alternative for patients who fail corticosteroid injections or require longer-duration relief. 1
• These interventions are particularly appropriate for grade 2 osteoarthritis with acute pain exacerbations. 1

Monitoring Plan

Follow-Up Timeline

• Recheck blood pressure, renal function (creatinine, BUN), and assess edema resolution at 2 weeks after stopping aceclofenac. 2
• Reassess pain control and neuropathic symptoms at 4 weeks after initiating gabapentin, as neuropathic pain medications require weeks to achieve full effect. 1
• Monitor for gabapentin side effects including dizziness, sedation, and gait instability, which increase fall risk in elderly patients. 1

Critical Pitfalls to Avoid

• Never restart NSAIDs in this patient, even at lower doses or with gastroprotection, as the cardiovascular and renal risks outweigh benefits in elderly hypertensive patients with chronic use. 1, 2, 6
• Do not use COX-2 selective inhibitors (celecoxib) as an alternative, as they carry the same renal and cardiovascular risks as traditional NSAIDs in elderly patients. 1
• Avoid combining acetaminophen with opioids initially; reserve opioids only for severe refractory pain after exhausting all other options, as opioids increase fall risk and have uncertain long-term benefits in osteoarthritis. 1
• Do not attribute all the pain to osteoarthritis progression; the neuropathic component (knee to ankle) requires separate targeted treatment with gabapentin or pregabalin. 1