In an elderly woman with controlled hypertension (HTN) who has been taking aceclofenac once daily (OD) for grade II knee osteoarthritis (OA) for four years and now presents with worsening knee pain, neuropathic pain radiating to the ankle, and mild‑to‑moderate swelling extending from the knee to the toes, what is the appropriate management and should Chymoral Forte be prescribed?

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

Immediate Action Required

Urgent vascular assessment with duplex ultrasound is mandatory before any medication changes—unilateral limb swelling from knee to toes in an elderly patient requires immediate exclusion of deep vein thrombosis, compartment syndrome, or other vascular/lymphatic pathology. 1

• The presence of neuropathic pain radiating below the knee combined with unilateral swelling indicates this is not simple osteoarthritis progression and demands combined neurological and vascular work-up before attributing symptoms solely to OA. 1
• Never overlook unilateral limb swelling; it requires urgent evaluation before modifying osteoarthritis therapy. 1

Discontinue Aceclofenac After 4 Years

Stop aceclofenac immediately—after 4 years of continuous NSAID use in an elderly hypertensive patient, the cumulative cardiovascular, gastrointestinal, and renal risks far outweigh any continued benefit, especially given treatment failure. 2, 1

• Prolonged NSAID courses should be avoided because adverse-event risk accumulates with longer exposure, particularly in elderly patients. 1
• NSAIDs cause clinically significant blood pressure elevations in hypertensive patients, with sustained elevations increasing risk of stroke, congestive heart failure, and ischemic cardiac events. 3, 4
• A recent study found NSAIDs implicated in 23.5% of hospitalizations for adverse drug reactions in older adults. 2

Stepwise Pharmacologic Management

Step 1: Acetaminophen as First-Line Therapy

Prescribe acetaminophen 650-1000 mg every 6-8 hours (maximum 3,000 mg daily in elderly patients) as the safest initial analgesic for this elderly hypertensive patient. 1, 5

• Acetaminophen provides pain relief comparable to NSAIDs in many older adults with knee osteoarthritis while avoiding cardiovascular, gastrointestinal, and renal hazards. 6, 1
• Regular scheduled dosing maintains consistent analgesic levels rather than waiting for pain to escalate. 5
• The reduced 3,000 mg daily maximum for elderly patients minimizes hepatotoxicity risk. 5
• Counsel the patient explicitly to avoid all other acetaminophen-containing products. 5

Step 2: Topical Diclofenac Before Any Oral NSAID

If acetaminophen alone is insufficient, add topical diclofenac gel 4 grams four times daily to the affected knee—this provides comparable pain relief to oral NSAIDs with minimal systemic absorption and dramatically lower cardiovascular and gastrointestinal risk. 6, 1

• Topical diclofenac demonstrated effect size of 0.91 compared to placebo while minimizing systemic exposure. 2, 6
• For patients ≥75 years, topical NSAIDs are strongly preferred over oral NSAIDs due to substantially greater risk for cardiovascular, gastrointestinal, and renal adverse reactions with oral agents. 6
• Topical NSAIDs are specifically recommended for patients with increased cardiovascular risk, which includes elderly hypertensive patients. 6

Step 3: Duloxetine for Neuropathic Pain Component

Add duloxetine 30 mg daily for one week, then titrate to 60 mg daily to address the neuropathic pain radiating below the knee to ankle. 1

• Duloxetine 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 targets the nerve pain component that acetaminophen and topical NSAIDs will not adequately address. 1

Step 4: Intra-Articular Corticosteroid Injection

Consider a single intra-articular corticosteroid injection for short-term pain relief if the knee swelling is confirmed to be joint effusion rather than systemic edema. 2, 1

• Intra-articular steroids provide short-term benefit with effect size of 1.27 over 7 days, particularly effective for acute exacerbations with effusion. 2
• This is strongly recommended for elderly patients who cannot tolerate oral NSAIDs. 1
• Injection is appropriate only after confirming that swelling is a joint effusion through clinical examination or imaging. 1

Essential Non-Pharmacologic Interventions

Implement joint-specific strengthening exercises and general aerobic conditioning alongside pharmacologic therapy—randomized trials report effect sizes of 0.57-1.0 for pain reduction. 1

• Both supervised and home-based exercise programs demonstrate reduced pain scores and improved function in multiple RCTs. 1
• Provide patient education, advise use of local heat or cold, and recommend assistive devices (walker or cane) with shock-absorbing footwear to reduce load on the knee. 1
• Weight reduction if overweight significantly decreases knee osteoarthritis symptoms. 1

Regarding Chymoral Forte (Trypsin-Chymotrypsin Enzyme)

Do not prescribe Chymoral Forte—there is no high-quality evidence supporting the use of oral proteolytic enzymes for osteoarthritis, and current guidelines do not recommend this agent. 1

• The evidence-based guidelines consistently recommend acetaminophen, topical NSAIDs, duloxetine, and intra-articular corticosteroids as proven therapies. 6, 1
• Similarly, do not prescribe glucosamine or chondroitin, as current evidence does not demonstrate efficacy for knee osteoarthritis. 1

Critical Safety Pitfalls to Avoid

• Never prescribe oral NSAIDs to an elderly hypertensive patient without first trying acetaminophen and topical NSAIDs, and never without concurrent proton-pump inhibitor for gastroprotection. 1
• If oral NSAIDs become absolutely necessary after all other options fail, use the lowest effective dose for the shortest possible duration with mandatory PPI co-prescription. 2, 1
• Assess renal function before any oral NSAID; use is contraindicated or requires extreme caution in renal insufficiency. 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

Monitoring Plan

• Recheck blood pressure within 2 weeks of starting any new analgesic regimen to ensure hypertension remains controlled. 3, 4
• Monitor liver enzymes (AST/ALT) if using maximum-dose acetaminophen long-term. 5
• Reassess pain and function at 2-4 weeks to determine if the stepwise approach is providing adequate relief. 1