The Use of Non-Steroidal Anti-Inflamatory Drugs as Pain Management Treatment for

Osteoarthritis Older Adults

Master of Nursing Studies

NURS7103: Adult and Elder Nursing
Critical Issue Essay

Lisa van Seters

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Word count: 1092
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Introduction to Osteoarthritis

Osteoarthritis, also known as ‘wear and tear arthritis’, is a joint disorder that is

characterised by the progressive degeneration of cartilage, inflammation of the synovial

membrane, changes in bone and periarticular muscle weakness, narrowing of the joint space

and arthralgia (Majeed, Sherazi & Bajwa, 2018; Man and Mologhianu, 2014). Osteoarthritis

is most commonly localised in weightbearing joints like the hands, feet, spine, knees and hips

and presents with pain, stiffness, as well as loss of function, mobility and independence

(March et. al., 2014). Osteoarthritis prevalence increases significantly with age however

certain aetiological factors such as genetic predisposition, obesity, traumatic joint injury,

mechanical stress, joint laxity, and muscle weakness also increase risk (Kim, Yoo & Kim,

2018). In Australia, the National Health Survey estimated that around 10% of all Australians

have osteoarthritis, and the prevalence rises exponentially to more than 60% in persons aged

over 55 (AIHW, 2015). Globally, osteoarthritis is ranked as the eleventh most disabling

disease and places an immense burden on individuals, healthcare systems and society

(RADGP, 2018).

Considering the high incidence and immense burden this disease poses, especially in

the elderly, it is critical for research bodies to investigate evidence-based treatment protocols.

However, the exact pathophysiology of Osteoarthritis remains uncertain so there are no

preventative strategies nor ‘cure’ (Kim, Yoo & Kim, 2018). In light of this, the content of

essay will focus on the pharmacological management of pain in osteoarthritis in older adult

patients and critically appraise the current state of the evidence for recommended pain

treatments; specifically, oral non-steroidal anti-inflammatory drugs (NSAIDs). Furthermore,

conclusions and recommendations on the use of NSAIDs in elderly populations will be

discussed including current limitations in the literature.

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The Pain Management of Osteoarthritis with NSAIDs

The effective management of osteoarthritis pain requires long term treatment plans

from multidisciplinary treatment teams (Gregori, et. al., 2018). The pharmacological

treatment of osteoarthritis (OA) focuses on relieving the associated symptoms such as joint

pain and inflammation (Steinmeyer et. al., 2018). NSAIDs are an internationally

recommended first-line analgesic for osteoarthritis and are the most commonly used

pharmacological pain management (Gregori et. al, 2018; Crofford, 2013; McAlindon et. al.,

2014). A majority of NSAIDs are affordable and easily accessed over-the counter in

pharmacies (Majeed, Sherazi & Bajwa, 2018). NSAIDs relieve pain and inflammation by

inhibiting the activity of cyclooxygenase (COX) enzymes by essentially impeding the

synthesis of prostaglandins (Crofford, 2013). Common NSAIDs include: Ibuprofen,

Celecoxib, Diclofenac, Etofenamate, Etoricoxib, Indomethacin, Licofelone, Naproxen,

Nimesulide, Rofecoxib, and Tiaprofenic acid (Gregori et. al., 2018). A number of placebo-

controlled studies have shown that NSAIDs anti-inflammatory and analgesic effects have

good efficacy against osteoarthritis pain (Bannuru et. al., 2015; Steinmeyer et. al., 2018).

However, despite the proven effectiveness in reducing pain and inflammation in osteoarthritis

patients, NSAIDs are associated with an abundance of risks, especially in older adults (Table

1).

Pain Management of Osteoarthritis in Older Adults

NSAIDs inhibit prostaglandin synthesis, and cause weakness in gastrointestinal

mucosal barrier (Wongrakpanich, Wongrakpanich, Melhado & Rangaswarmi, 2018). As

such, NSAIDs are notorious for triggering gastrointestinal bleeding and ulceration, and this

effect is four times more prominent in elderly patients (Sabzwari, Qidwai, & Bhanji, 2013).

To reduce the gastrointestinal risks, alternate COX-2 inhibitors were developed. However,

these are correlated with an increased risk of cardiovascular problems (Zeng et. al., 2016).

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Renal side effects of NSAIDs occur due to reduced blood flow to kidneys are less common

than gastrointestinal and cardiovascular risks (Wongrakpanich et. al., 2018). However, older

age patients are at risk of developing nephrotoxicity from NSAIDs due to reduced kidney and

metabolic function (Wongrakpanich et. al., 2018). To counter the adverse effects of

gastrointestinal problems, it is recommended that NSAIDs are combined with proton pump

inhibitors to reduce gastric acid production (Zeng et. al., 2018). However, this causes further

problems of polypharmacy.

Polypharmacy increases the risk of falls in the elderly. Since NSAIDs are a ‘fall-risk

increasing drug’ this is of additional concern as falls are positively associated with fractures

and the fifth leading cause of mortality (Richardson, Bennet & Kenny, 2015; Dhalwani et. al,

2017). Furthermore, NSAIDs are associated with adverse drug-drug interactions (Moore,

Pollack & Butkerait, 2015). This becomes an increasingly difficult problem as patient age,

and the number of medications increase. This is yet another reason that NSAIDs should be

prescribed with caution in the elderly.

NSAIDs are the recommended first-line pain management of osteoarthritis. However,

they are associated with adverse gastrointestinal, cardiovascular and renal side-effects and

increase the risk of falls for elder populations in particular. Osteoarthritis patients should be

educated about the possibility of NSAID adverse effects occurring, so that they can be aware

and inform healthcare practitioners and alternate pain management can be sourced

(Charlesworth et. al., 2019). Nonpharmacological pain managements such as exercise and

weight management are effective in management of osteoarthritis and should also be

advocated due to low risk of harm, cost effectiveness as well as associated health benefits

(Nejati, Farzinmehr, & Moradi-Lakeh, 2015).

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Table 1.

Comprehensive list of adverse side-effects of NSAIDs in the elderly as described by

Wongrakpanich and colleagues (2018).

System Affected Adverse Effects

Gastrointestinal Dyspepsia
Gastroduodenal ulcers
Gastrointestinal bleeding and perforation
Cardiovascular Edema
Hypertension
Congestive heart failure
Myocardial infarction
Stroke and other Thrombotic events
Renal Electrolyte imbalance
Sodium retention
Edema
Reduce glomerular filtration rate
Nephrotic syndrome
Acute interstitial nephritis
Renal papillary necrosis
Chronic kidney disease

Conclusions and Recommendations for NSAID Use in Older Adults

When providing nursing care of the elderly, being aware of drug mechanisms,

evidence-based guidelines, common drug side effect, and drug interactions are critically

important. NSAIDs are considered the first-line pain management pharmaceutical for

osteoarthritis, however, they have many adverse side effects and drug interactions; especially

in older adults (Zeng et. al., 2019). In light of this, NSAIDs should only be prescribed for the

shortest duration, with the lowest dose and be used intermittently in order to reduce the risk

of adverse effects (Majeed et. al., 2018). The recommended short-term use of NSAIDs is

therefore problematic as it contradicts the progressive and debilitating osteoarthritis course.

Therefore, use in elderly populations can only safely be achieved whilst closely monitoring

for NSAID dose, duration and for gastrointestinal, cardiovascular or renal toxicity

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(Wongrakpanich et. al., 2018). The use of NSAIDs becomes even more complicated as it is a

‘falls risk increasing medication’ and increases risk of mortality. The risks and benefits

should therefore be carefully investigated on a case-by-case basis to assess whether the

analgesic and anti-inflammatory benefits of NSAIDs outweigh the potential longer-term risk

to optimise pain management outcomes, especially in consideration of older adults’ frailty

(Wongrakpanich, et. al., 2018).

References

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