Treating severe OA in a complex patient

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spacecowgirl

spacecowgirl

in the bee-loud glade
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Had this case today and I'm wondering what you guys would do to compare with what we decided.

The pt is 85 yo male, a fib, compensated CHF (EF 65%), multi-infarct dementia, hypertension. Other meds: warfarin, lisinopril, furosemide, citalopram, ciprofloxacin (has catheter), atenolol. CrCl is 45 ml/min, normal CBC, INR within range.

He can be cared for at home if he is able to ambulate. Right now the pain from OA in his ankles is so severe that he will have to go to a nursing home.

Thoughts?
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I don't have time to pick through each part of this case, but in general:
APAP is first line if there is no inflammation. NSAIDS would come into play if there's inflammation.
 
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you could add a cane or a walker, or those funny looking really padded shoes
 
Can I get back to you on this? Like tomorrow or something? We just did OA, so it's really fresh right now. :)

Also, I don't want to be ridiculed if I say something wrong, because I didn't have the time to dig deep into this case but posted anyway.
 
spacecowgirl said:
Had this case today and I'm wondering what you guys would do to compare with what we decided.

The pt is 85 yo male, a fib, compensated CHF (EF 65%), multi-infarct dementia, hypertension. Other meds: warfarin, lisinopril, furosemide, citalopram, ciprofloxacin (has catheter), atenolol. CrCl is 45 ml/min, normal CBC, INR within range.

He can be cared for at home if he is able to ambulate. Right now the pain from OA in his ankles is so severe that he will have to go to a nursing home.

Thoughts?
Click to expand...

If it's "severe", then APAP alone won't be enough.

you can try one of those intraarticular hyluronic acid (sp?) injections. Efficacy equals to naproxen. Intraarticular corticosteriod might be ok, but I don't know how much systemic exposure/problem it would create for a CHF patient.

Voltaren cream, not sure how much less systemic exposure it is. Tramadol has been used when NSAIDs can't be. Glucosamine + condroitin might be worth giving a shot as well.
 
Glucosamine (don't need the chondroitin) can take months to work. He can't put weight on his legs for canes/walker/brace. Medical MJ isn't legal in my state. Voltaren cream isn't covered and it would be hard to use d/t his dementia.

C'mon people, I want real pharmaceutical options here! This is a real pt and you will get questions like this!!!
 
What has he tried already but failed? That would be given in the real world...
 
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I would be really concerned about GI bleeding in an 85 year old patient on warfarin... therefore, my answer would be Celecoxib. High dose IBU or naproxen, which would probably be necessary considering the severity, would be a problem. If the hypertension is controlled, then there would be less to worry about if giving NSAIDS. Where's the a fib medication? Is the CHF being managed appropriately or is it still progressing?

http://effectivehealthcare.ahrq.gov/healthInfo.cfm?infotype=sg&DocID=4&ProcessID=2#section5

ETA: Like high dose IBU and naproxen, opiods would be problematic for an 85 yo patient, too, because of the risk of sedation and constipation. If an 85 yo patient falls due to sedation, then the benefits of the analgesic effect would be outweighed by the risks associated with hip surgery post-fall. If I remember correctly, 20% of patients who undergo hip surgeries do not make it past 1 year post-op.
 
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You start with APAP and monitor the pain. Does you provide any relief? Enough to ambulate a little. If this fails you have several choices:


  • Appeal the coverage decision on the Voltaren Gel.
  • Add a narcotic analgesic and monitor the patient's mental status.
  • Intraarticualr steroids with an NSAID and monitor the CHF, HTN and coagulation status.
There really are NO good choices in some situations and that's why machines will never replace doctors and pharmacists because there is an art to medicine and pharmacy that can never be automated.....
 
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Old Timer said:
There really are NO good choices in some situations and that's why machines will never replace doctors and pharmacists because there is an art to medicine and pharmacy that can never be automated.....
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Agreed! Let's say for the sake of argument that APAP didn't work. CHF is not progressing.

Pt is on coumadin for a fib. Pt has no h/o GI bleed, no h/o of PI or H2 blocker use.
 
PharmDstudent said:
If an 85 yo patient falls due to sedation, then the benefits of the analgesic effect would be outweighed by the risks associated with hip surgery post-fall.
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Would it? From what standpoint are risks>benefits - mortality or QOL? I don't know myself, just a hypothetical question.
 
Tramadol is anoption but I'd worry about the theoretical interaction with the ssri and serotonin syndrome.
 
spacecowgirl said:
Would it? From what standpoint are risks>benefits - mortality or QOL? I don't know myself, just a hypothetical question.
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The mortality associated with hip surgery is pretty high.

This is an older article, but I think the results of the article are still relevant.

Predictors of mortality and institutionalization after hip fracture: the New Haven EPESE cohort. Established Populations for Epidemiologic Studies of the Elderly.
R A Marottoli, L F Berkman, L Leo-Summers, and L M Cooney, Jr

Results section- "Of 120 individuals suffering a hip fracture, 22 (18%) died within 6 months and 35 (29%) were institutionalized at 6 months."
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1615208


My thoughts are purely anecdotal, but I used to work in a nursing home and the old folks would have so many problems with walking. Whenever a lady that I was caring for fell, it really freaked me out; she was one of our favorite residents, too. Sometimes residents would fall over if they were being placed in their beds from a wheelchair; you really had to find out if they had enough arm strength to support themselves or if they needed a hydraulic-type of lift instead.
 
njac said:
Tramadol is anoption but I'd worry about the theoretical interaction with the ssri and serotonin syndrome.
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Meh. I wouldn't worry too much about that.
PharmDstudent said:
The mortality associated with hip surgery is pretty high.
Click to expand...
I agree, I'm not debating that at all. My question is more, would you trade a 20% risk of death for say, an 80% chance of ambulation-->living at home vs. NH--> increased QOL?
 
spacecowgirl said:
I agree, I'm not debating that at all. My question is more, would you trade a 20% risk of death for say, an 80% chance of ambulation-->living at home vs. NH--> increased QOL?
Click to expand...
Sure. Living at home would be far better than living in a nursing home, IMHO. If opiods work, then perhaps the patient and caregiver should be counseled about the risk of falling and about how to minimize the risk by removing clutter, keeping walk ways clear, installing handrails, etc.
 
spacecowgirl said:
Agreed! Let's say for the sake of argument that APAP didn't work. CHF is not progressing.

Pt is on coumadin for a fib. Pt has no h/o GI bleed, no h/o of PI or H2 blocker use.
Click to expand...

Don't cherry pick my answer. Accept it or argue against it....

Perhaps the steroids would lessen the inflammation and pain to the point where APAP wpuld relieve same?
 
PharmDstudent said:
I would be really concerned about GI bleeding in an 85 year old patient on warfarin... therefore, my answer would be Celecoxib. High dose IBU or naproxen, which would probably be necessary considering the severity, would be a problem.
Click to expand...

I always hate seeing this drug used in cardiac patients because of the shift in the Thromboxane A2/COX balance. However, if the patient's CHF isn't that terrible (EF of 65%) and his QOL is that severely compromised, the benefits may outweigh the risks.

Personally, I'd go with APAP/intraarticular corticosteroids if the patient tolerates. Celecoxib would be my 2nd option, followed by opiods/bowel maintenance. Please, for God's sake, no Darvocet!

On another note, for a long-term non-systemic option, does the patient's mental status prohibit him from using something like Capsaicin cream? I've had some patients who had good responses with it. Granted, it takes 4-6 weeks before the substance P is depleted, but it might be worth a shot.
 
dumediat said:
I always hate seeing this drug used in cardiac patients because of the shift in the Thromboxane A2/COX balance. However, if the patient's CHF isn't that terrible (EF of 65%) and his QOL is that severely compromised, the benefits may outweigh the risks.

Personally, I'd go with APAP/intraarticular corticosteroids if the patient tolerates. Celecoxib would be my 2nd option, followed by opiods/bowel maintenance. Please, for God's sake, no Darvocet!

On another note, for a long-term non-systemic option, does the patient's mental status prohibit him from using something like Capsaicin cream? I've had some patients who had good responses with it. Granted, it takes 4-6 weeks before the substance P is depleted, but it might be worth a shot.
Click to expand...
I know. All NSAIDS, as far as I know, have that risk, though, but since the patient has inflammation... whatcha ya gonna do?

Injecting corticosteroids seems pretty involved. You also have more of a risk of infection if the shots are given at home by a home health nurse... or so I've read. (???)



It's hard to chose, you know?

images
 
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That's why I would lead towards APAP if at all possible. Again, as far as infection, if the benefit outweighs the risk (which I think would be the case in this patient) I would try that option.
 
Old Timer said:
Don't cherry pick my answer. Accept it or argue against it....

Perhaps the steroids would lessen the inflammation and pain to the point where APAP wpuld relieve same?
Click to expand...

:confused: What are you talking about? I was agreeing with your last statement and answering PharmD's question about whether APAP had been tried. Simma down now, Old Timer, it's ok.
 
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PharmDstudent said:
Injecting corticosteroids seems pretty involved. You also have more of a risk of infection if the shots are given at home by a home health nurse... or so I've read. (???)
Click to expand...

If you're going to go the injection route i would go with HA instead of a corticosteroids. The efficacy of HA is longer than the corticosteroids and lower incidence of side effects.

As far as the opioid analgesics, ask the patient if he would prefer to be at home taking opioids and sedated or in a nursing home. If he chooses to stay at home (which i'm assuming he will) take the extra effort to counsel him and whoever he lives with. Before he starts on the medication, get rid of anything he could trip on, carpets, ect. Tell him every day to do squats into a chair (so if he falls he'll just sit down) because the load bearing exercise should help his OA and bone density. Other than that, with the meds hes on and age hes at, I would be worried using other medications such as NSAIDs (even the voltaren gel becuase while systemic absorption is reduced it could still be substantial enough to cause problems with the warfarin). Any other options have left my mind since OA was beginning of last semester....
 
dumediat said:
That's why I would lead towards APAP if at all possible. Again, as far as infection, if the benefit outweighs the risk (which I think would be the case in this patient) I would try that option.
Click to expand...
What about the inflammation? Will APAP work for inflammation?

NSAIDS are recommended if the patient has inflammation.
 
VCU2011 said:
If you're going to go the injection route i would go with HA instead of a corticosteroids. The efficacy of HA is longer than the corticosteroids and lower incidence of side effects.
Click to expand...
I know of HA to mean headache. So, I'm a little lost. :p
 
I'd consider orthopedic surgery if there is evidence of bone spurs, etc. Otherwise I'd try tramadol and IA steroids and/or IA synvisc (off lable for ankle use).
 
npage148 said:
OMG! read some OA guidelines and get back to us.

I'm still sticking by APAP, maybe a 1/2 lortab 2.5 prn. and bracing/support
Click to expand...
You provide the guidelines... if you think you know it all. :smuggrin:

We were taught, straight-up, that in general, APAP is used without inflam and NSAIDS are used with inflam.


ETA: Here. I'll post some for you mouseboy. :smuggrin:

"Pharmacologic therapy
All of the pharmacologic agents discussed in this section should be considered additions to nonpharmacologic measures, such as those described above, which are the cornerstone of OA management and should be maintained throughout the treatment period. Drug therapy for pain management is most effective when combined with nonpharmacologic strategies (30).
For many patients with OA, the relief of mild-to-moderate joint pain afforded by the simple analgesic, acetaminophen, is comparable with that achievable with an NSAID (8,10;31-33). Furthermore, Bradley and colleagues failed to demonstrate differences in responses to acetaminophen and ibuprofen in knee OA patients with clinical features of joint inflammation (34). However, this finding was based on a post hoc analysis with limited statistical power that used a definition of inflammation which included joint-line and soft-tissue tenderness or soft-tissue swelling. Eccles and colleagues, in a metaanalysis of trials comparing simple analgesics with NSAIDs in patients with knee OA, did note that NSAID-treated patients had significantly greater improvement in both pain at rest and pain on motion (33).
Two recent trials, findings of which were presented at the ACR's 1999 annual meeting, also provide data on the relative efficacy of acetaminophen and NSAIDs in patients with OA. In one study, acetaminophen and ibuprofen were comparably effective in patients with mild-to-moderate pain, but ibuprofen was statistically superior to acetaminophen in patients with SEVERE pain (35); in the other study, diclofenac was statistically SUPERIOR to acetaminophen for both pain and function measured with several validated outcome measures (36). Furthermore, two recent studies of patients with OA demonstrated greater preference for NSAIDs than for acetaminophen, although many patients continue to take acetaminophen (13,14). Nevertheless, although A NUMBER OF PATIENTS MAY FAIL to obtain adequate relief even with full doses of acetaminophen, this drug merits a trial as initial therapy, based on its overall cost, efficacy, and toxicity profile (33,37). In patients with knee OA with moderate-to-SEVERE pain, and in whom signs of joint inflammation are present, joint aspiration accompanied by intraarticular injection of glucocorticoids or prescription of an NSAID merits consideration as an alternate initial therapeutic approach."


American College of Rheumatology
http://www.rheumatology.org/publications/guidelines/oa-mgmt/oa-mgmt.asp
 
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PharmDstudent said:
I know. All NSAIDS, as far as I know, have that risk, though, but since the patient has inflammation... whatcha ya gonna do?

Injecting corticosteroids seems pretty involved. You also have more of a risk of infection if the shots are given at home by a home health nurse... or so I've read. (???)



It's hard to chose, you know?

images
Click to expand...

It's a one shot deal before discharge. Patient go home w/o being able to ambulate. Steroids and analgesics appear to the best choice unless the OP is ready to share what her team came up with...
 
Old Timer said:
It's a one shot deal before discharge. Patient go home w/o being able to ambulate. Steroids and analgesics appear to the best choice unless the OP is ready to share what her team came up with...
Click to expand...
Ok. I'm wasn't familiar with the procedure. Sounds dandy. :)
 
PharmDstudent said:
Two recent trials, findings of which were presented at the ACR's 1999 annual meeting, also provide data on the relative efficacy of acetaminophen and NSAIDs in patients with OA. In one study, acetaminophen and ibuprofen were comparably effective in patients with mild-to-moderate pain, but ibuprofen was statistically superior to acetaminophen in patients with SEVERE pain (35); in the other study, diclofenac was statistically SUPERIOR to acetaminophen for both pain and function measured with several validated outcome measures (36). Furthermore, two recent studies of patients with OA demonstrated greater preference for NSAIDs than for acetaminophen, although many patients continue to take acetaminophen (13,14). Nevertheless, although A NUMBER OF PATIENTS MAY FAIL to obtain adequate relief even with full doses of acetaminophen, this drug merits a trial as initial therapy, based on its overall cost, efficacy, and toxicity profile (33,37). In patients with knee OA with moderate-to-SEVERE pain, and in whom signs of joint inflammation are present, joint aspiration accompanied by intraarticular injection of glucocorticoids or prescription of an NSAID merits consideration as an alternate initial therapeutic approach."
Click to expand...

I'm going to put emphasis on "as an alternate initial therapeutic approach." That doesn't mean that this is the only option, but merits consideration as a possible initial choice of therapy.

This is all well and good, but what about patients in which NSAID's are contraindicated? In this case, since the patient has CHF, I would try APAP first, then celecoxib second. And no, of course APAP doesn't treat inflammation, but the intraarticular corticosteroids would.

You also forgot to post this little ditty from the same source that you cited:

Risk factors for upper GI bleeding in patients treated with NSAIDs include age >=65 years, history of peptic ulcer disease or of upper GI bleeding, concomitant use of oral glucocorticoids or anticoagulants, presence of comorbid conditions, and, possibly, smoking and alcohol consumption (Table 2) (47-49). Risk factors for reversible renal T2 failure in patients with intrinsic renal disease (usually defined as a serum creatinine concentration of >=2.0 mg/dl) who are treated with NSAIDs include age >=65 years, hypertension and/or congestive heart failure, and concomitant use of diuretics and angiotensin-converting enzyme inhibitors (50).
 
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dumediat said:
That's all well and good, but what about patients in which NSAID's are contraindicated? In this case, since the patient has CHF, I would try APAP first, then celecoxib second. And no, of course APAP doesn't treat inflammation, but the intraarticular corticosteroids would.
Click to expand...
Yes. Contraindications are a problem. You're right, and my head hurts. Complicated ID issues and journal club articles don't mix! :p ...thankfully intraarticular injections are easier to administer than I had imagined.

Now where's spacecowgirl?
images






I think it's officially my nap time. :sleep:

ETA:
dumediat said:
I'm going to put emphasis on "as an alternateinitial therapeutic approach." That doesn't mean that this is the only option, but merits consideration as a possible initial choice of therapy.

This is all well and good, but what about patients in which NSAID's are contraindicated? In this case, since the patient has CHF, I would try APAP first, then celecoxib second. And no, of course APAP doesn't treat inflammation, but the intraarticular corticosteroids would.

You also forgot to post this little ditty from the same source that you cited:

Risk factors for upper GI bleeding in patients treated with NSAIDs include age >=65 years, history of peptic ulcer disease or of upper GI bleeding, concomitant use of oral glucocorticoids or anticoagulants, presence of comorbid conditions, and, possibly, smoking and alcohol consumption (Table 2) (47-49). Risk factors for reversible renal T2 failure in patients with intrinsic renal disease (usually defined as a serum creatinine concentration of >=2.0 mg/dl) who are treated with NSAIDs include age >=65 years, hypertension and/or congestive heart failure, and concomitant use of diuretics and angiotensin-converting enzyme inhibitors (50).
Click to expand...
I've already addressed almost all of that.
 
I know, I just don't like it when people use part of a source to prove a point, but fail to mention the parts that go against their statement.
 
dumediat said:
I know, I just don't like it when people use part of a source to prove a point, but fail to mention the parts that go against their statement.
Click to expand...
You aren't being biased are you? :p
 
- Should be on ACE-inhibitor

- Tylenol -> start 2 g OD.


You guys pushing NSAIDs are nuts.

For the acute inflammation, try an intraarticular corticosteroid.

To the person "really concerned about GI bleed in an 85 year old pt on warfarin", read the BAFTA trial. Warfarin at a therapeutic INR does not have a higher bleeding risk than ASA. Trial was in elderly atrial fibrillation patients.

Take it from there.

Perhaps add on aricept (donepezil) for dementia. Gotta get that on board quickly in those pts.
 
Requiem said:
- Should be on ACE-inhibitor

- Tylenol -> start 2 g OD.


You guys pushing NSAIDs are nuts.

For the acute inflammation, try an intraarticular corticosteroid.

To the person "really concerned about GI bleed in an 85 year old pt on warfarin", read the BAFTA trial. Warfarin at a therapeutic INR does not have a higher bleeding risk than ASA. Trial was in elderly atrial fibrillation patients.

Take it from there.

Perhaps add on aricept (donepezil) for dementia. Gotta get that on board quickly in those pts.
Click to expand...

He's on lisinopril. Just a question...does Aricept have any benefit with respect to dementia when it's related to infarct, as opposed to a degenerative process like Alzheimer's?
 
spacecowgirl said:
Had this case today and I'm wondering what you guys would do to compare with what we decided.

The pt is 85 yo male, a fib, compensated CHF (EF 65%), multi-infarct dementia, hypertension. Other meds: warfarin, lisinopril, furosemide, citalopram, ciprofloxacin (has catheter), atenolol. CrCl is 45 ml/min, normal CBC, INR within range.

He can be cared for at home if he is able to ambulate. Right now the pain from OA in his ankles is so severe that he will have to go to a nursing home.

Thoughts?
Click to expand...


First you have to make sure there is nothing else going on (gout, psoriatic arthritis, extra-articular systemic manifestation, pseudogout, septic joint, occult fracture, etc)

I would have PT and OT first see and evaluate the patient. He may qualify for rehab (either acute or subacute) instead of a nursing home. OT may help with lifestyle modifications and there are a lot of gadgets that can help someone with severe OA (ie help putting on shoes, socks, etc).

Depending on his functioning level, he may be a candidate for either intra-articular hyaluronic acid injection or intra-articular steroid injection.

Tylenol would be my first line choice, but if that doesn't work, trying low dose narcotics may be reasonable - he just needs close follow-up with his PCP and his primary caretaker at home needs to be aware of what narcotics can do with elderly patients.

Heat therapy (either a heating pad or physical therapy using ultrasound) may also be beneficial.
 
I guess it's fair to say that I'm biased against using half-truths to make points...although that's not really the right usage of the word.
 
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StaviZFingerZ said:
Are you questioning my clinical authority? :smuggrin:
Click to expand...

Authority, no. Recommendation in this case, Yes. You don't add salicylates, topical or systemic to a patient on Warfarin with a stable INR.
 
Old Timer said:
Authority, no. Recommendation in this case, Yes. You don't add salicylates, topical or systemic to a patient on Warfarin with a stable INR.
Click to expand...

Agreed.

It seems like half this thread is full of people jumping to the guidelines without considering the patient himself. Sure, NSAIDs may be great as a first-line treatment for OA - IN GENERAL, but this patient isn't "general"...he's complicated. He has CHF, crappy kidneys, is on warfarin and he's 85 years old. I agree that low-dose analgesics would probably be the best bet with him. Problem with steroids is that he already has hypertension and CHF. Increasing his blood pressure and causing water retention could cause some pretty serious problems for him. In an 85 year old, it wouldn't take much.

This would be a good time to assess the patient's goals of therapy. Would he prefer pain relief over functionality or would he be alright with some pain as long as he was able to stay fairly alert?
 
dumediat said:
Just a question...does Aricept have any benefit with respect to dementia when it's related to infarct, as opposed to a degenerative process like Alzheimer's?
Click to expand...

Maybe. There's "modest" evidence that Namenda might help improve symptoms of vascular dementia, but not much out there on Aricept. I guess Razadyne tried to get approval for stroke-related dementia but their studies didn't really pan out. Maybe it depends on which neurologist you ask. Some will give it a try (not many options) and others won't.
 
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