Problem of arthritis treatment in elderly

My father complained of pain in his right knee about one year ago. Initially he ignored it, thinking it to be due to overexertion but gradually the pain increased in intensity. There was restriction of movement in of the right knee joint. On examination, he was provisionally diagnosed as having osteoarthritis of the knee, confirmed with X-ray. He was prescribed Diacrein tablets and Aceclofenac 100 mg for pain control along with antacids. What happened next highlights the problem of treatment of arthritis in the elderly.

His arthritis was well controlled with medications. But after about 7 months on the treatment, he started feeling shortness of breath when he used the stairs. His blood pressure also spiked. When I examined him, I thought I have heard an ejection systolic murmur. Understandably I was worried. All the bad diagnoses came to my mind. He was examined by a cardiologist, my teacher actually, but he disagreed about the murmur. To establish a diagnosis, an ECG, chest X-ray and echocardiography was performed. Nothing was found. The cardiologist asked to discontinue the Aceclofenac and arranged for follow-up. A coronary angiogram was scheduled to be performed if the shortness of persisted on follow-up. On discontinuation of aceclofenac, my father did not complain of any shortness of breath. Presently, his arthritis is well controlled with acetaminophen (paracetamol).

This small anecdote demonstrates the problem in the control of pain in elderly arthritis patients besides the gastrointestinal problems caused by NSAIDs. Treatment of pain with Non steroidal anti inflammatory drugs (NSAIDs) causes significant cardiovascular problems. Several studies have shown NSAID use in elderly is an independent risk factor for hypertension (links given below). NSAIDs block the cyclooxygenase enzyme, nonselective NSAIDs block both COX-1 and COX-2 isoforms. COX-1 synthesize prostaglandins which are responsible for vasodilation and COX-2 produce prostaglandins which maintain diuresis and natriuresis. NSAIDs, thus may hypertension either by blocking the natriuresis causing sodium and water retention and by blocking vasodilation and production of vasoconstricting endothelins. A careful history taking is therefore of paramount importance while NSAIDs are prescribed to elderly as hypertension is a major risk factor for a variety of cardiovascular problems like myocardial infarction, stroke etc.

Currently there is interest in another novel group of drugs, which are CINODs (Cyclooxygenase inhibiting nitric oxide donators), which have much favourable gastrointestinal profile, and less chance of development of hypertension. As far as I know, at present CINODs are not marketed in India, but the introduction of CINODs will open up a new option arthritis treatment.

Links:

NSAID and hypertension

1.                  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1381681/

2.                  http://www.ncbi.nlm.nih.gov/pubmed/9467684?ordinalpos=1&itool=PPMCLayout.PPMCAppController.PPMCArticlePage.PPMCPubmedRA&linkpos=1

CINODs

1.                  http://www.ingentaconnect.com/content/ben/chamc/2006/00000004/00000002/art00004