How should I manage an elderly woman with well‑controlled hypertension and grade‑2 knee osteoarthritis who has been taking aceclofenac daily for four years and now presents with increased knee pain, neuropathic pain radiating to the ankle, and unilateral swelling from below the knee to the toes?

Management of Worsening Knee Pain with Neuropathic Features and Unilateral Limb Swelling

Stop aceclofenac immediately and arrange urgent duplex ultrasound of the swollen limb within 24–48 hours to exclude deep-vein thrombosis before making any changes to osteoarthritis therapy. 1

Immediate Diagnostic Priorities

The unilateral limb swelling from knee to toes is a red flag that demands vascular assessment before attributing symptoms to osteoarthritis progression alone. 1

• Elderly patients on long-term NSAIDs who develop new unilateral leg swelling require urgent evaluation for deep-vein thrombosis, compartment syndrome, or other serious vascular/lymphatic pathology. 1
• The combination of neuropathic pain radiating below the knee plus unilateral edema mandates combined neurological and vascular work-up to exclude non-osteoarthritic causes. 1
• NSAIDs, including aceclofenac, can destabilize blood pressure control in hypertensive patients and cause fluid retention, edema, and weight gain through suppression of renal prostaglandins. 2, 3

Why Aceclofenac Must Be Stopped Now

Four years of continuous oral NSAID use in an elderly hypertensive patient has exposed her to cumulative cardiovascular, gastrointestinal, and renal risks that now outweigh any benefit. 4

• Elderly patients (≥75 years or approaching that age) have markedly increased risk of NSAID-related gastrointestinal bleeding, cardiovascular events, and nephrotoxicity that rises steeply with advancing age and duration of exposure. 4
• Prolonged NSAID courses should be avoided because adverse-event risk accumulates with longer exposure, especially in the elderly. 4
• The edema may resolve within days to a few weeks after stopping the oral NSAID. 2

Revised Analgesic Strategy After NSAID Discontinuation

Step 1: Topical NSAID as Primary Therapy

Switch to topical diclofenac gel 40 mg (2 pump actuations) applied to each painful knee twice daily—this provides pain relief equivalent to oral NSAIDs while eliminating systemic cardiovascular, gastrointestinal, and renal risks. 4, 1, 5

• The American Geriatrics Society strongly recommends topical NSAIDs over oral NSAIDs for patients ≥75 years due to substantially greater risk for systemic adverse reactions with oral agents. 4
• Topical diclofenac demonstrates equivalent efficacy to oral NSAIDs (effect size 0.91 vs. placebo) with minimal systemic absorption and no associated fluid retention. 4, 2
• Apply to clean, dry skin; wash hands after use; wait 30 minutes before showering; avoid covering with clothing until completely dry. 5

Step 2: Add Acetaminophen for Baseline Analgesia

Prescribe acetaminophen 1000 mg three times daily (total 3000 mg/day) as scheduled dosing, not "as needed," to provide sustained background pain control. 1

• Acetaminophen is the safest first-line agent and provides pain relief comparable to NSAIDs in many older adults with knee osteoarthritis. 1
• Regular scheduled dosing throughout the day provides better sustained pain control than "as needed" dosing. 1
• The 3000 mg daily limit in elderly patients balances efficacy with low hepatotoxicity risk. 1

Step 3: Target the Neuropathic Pain Component

Start duloxetine 30 mg once daily for one week, then increase to 60 mg daily to address the neuropathic pain radiating below the knee. 1

• Duloxetine is conditionally recommended for knee osteoarthritis with a neuropathic pain component and improves both osteoarthritic and neuropathic pain when used alone or in combination with other analgesics. 1
• Doses above 60 mg do not add benefit and increase adverse effects. 1
• This addresses the "nerve pain below knee to ankle" that suggests a neuropathic component beyond simple osteoarthritis. 1

Step 4: Intra-Articular Corticosteroid for Acute Flare

If the knee has a palpable effusion (joint swelling), perform a single intra-articular corticosteroid injection to provide short-term relief for the acute flare. 1

• Intra-articular corticosteroid injection is strongly recommended for elderly patients who cannot tolerate oral NSAIDs and provides short-term pain relief for acute flares with joint effusion. 1
• This is appropriate only after confirming that the swelling is a joint effusion rather than systemic edema. 1

Essential Non-Pharmacologic Interventions (Start Immediately)

Prescribe a structured exercise program with joint-specific quadriceps strengthening and general aerobic conditioning—this produces moderate to large pain reductions (effect sizes 0.57–1.0) and must accompany any pharmacologic therapy. 1, 2

• Both supervised and home-based exercise programs demonstrate reduced pain scores and improved function in multiple randomized trials. 1
• Provide patient education, recommend local heat or cold applications, and advise use of a cane or walker with shock-absorbing footwear to reduce load on the knee. 1
• If the patient is overweight, weight reduction significantly decreases knee osteoarthritis symptoms and is strongly recommended. 1, 2

Blood Pressure and Edema Monitoring After NSAID Cessation

Measure blood pressure at baseline, then again at 1 week and 2 weeks after stopping aceclofenac to detect any residual hypertensive effect. 2

• NSAIDs destabilize blood pressure control in hypertensive individuals; rises in pressure are frequently accompanied by edema and weight gain. 2
• Evaluate edema resolution at 1 week; if edema persists beyond 2 weeks after stopping aceclofenac, investigate alternative etiologies such as venous insufficiency, heart failure, or confirmed DVT. 2

Critical Safety Pitfalls to Avoid

• Never overlook unilateral limb swelling—it requires urgent vascular evaluation before attributing symptoms solely to osteoarthritis progression. 1
• Never prescribe oral NSAIDs to an elderly patient without concurrent gastro-protective therapy (proton-pump inhibitor), and only after topical agents have failed. 4, 1
• Do not prescribe glucosamine or chondroitin supplements—current evidence does not demonstrate efficacy for knee osteoarthritis. 1
• Reserve tramadol and other opioids for absolute last-line use after all other options have been exhausted, due to high toxicity, dependence risk, and limited long-term benefit. 1
• Never combine topical diclofenac with an oral NSAID unless the benefit outweighs the risk, and conduct periodic laboratory evaluations if combination therapy is unavoidable. 5

Follow-Up Timeline

• 24–48 hours: Duplex ultrasound result to rule out DVT 1
• 1 week: Blood pressure check, edema assessment, pain control evaluation 2
• 2 weeks: Blood pressure recheck, confirm edema resolution, assess duloxetine tolerability and titration 2
• 4 weeks: Reassess overall pain control with topical diclofenac and duloxetine; consider intra-articular injection if inadequate response 1