Nonsteroidal Anti-Inflammatory Drug Use in the Elderly: Issues of Compliance and Safety
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• • Nonsteroidal anti-inflammatory drug use in the elderly: Issues of compliance and safety JEFFREY T. KIRCHNER, DO Many of the goals in caring for swelling.2 Nonsteroidal anti-inflammatory drugs patients with non-life-threatening rheumat (NSAIDs) are frequently used to achieve these ic conditions can be safely met with non goals. An estimated 100 million prescriptions for steroidal anti-inflammatory drug (NSAID) NSAIDs were written in 1986 alone.4 Develop therapy. These drugs relieve pain and stiff ing an effective therapeutic regimen can be chal ness and help to maintain joint mobility. lenging, as there are clinical differences among However, no course of treatment can be suc the classes of NSAIDs. Moreover, wide variabil cessful without patient compliance. The dif ity exists in individual responsiveness to these ficulties of following dosage requirements drugs and their risk of adverse events.4 Table 1 and scheduling, together with the increased outlines guidelines for the administration of risk of adverse side effects, are particular NSAID therapy in the elderly. problems for the elderly-the very patients A complicating factor is the ability of the who are the major consumers of NSAIDs. patient to comply with the prescribed regimen. Com The key to successful NSAID therapy is main pliance becomes a particular concern in the case taining patient comfort and function while of the elderly who comprise just 12% of the gen using the simplest and safest medical regi eral population but consume 40% of all NSAIDs men available. The author discusses ways prescribed in the United States.5 in which these goals can be achieved. In general, compliance with medications for (Key words: Elderly, arthritis, nonsteroidal rheumatic disease is directly related to pain: the anti-inflammatory drugs [NSAIDs], compli more severe the patient's pain, the more compli ance) ance there will generally be with a given med ication.6 This may be the reason patients with Approximately one third of all adults in the rheumatoid arthritis are more compliant than United States have some symptoms of muscu those with osteoarthritis.6 Therefore, the dosing loskeletal disease. 1 These disorders range from rel and scheduling of NSAIDs usually should be atively benign entities, such as bursitis and ten titrated with symptoms. This titration gives the dinitis, to life-threatening illnesses, including individual the opportunity to manage his or her systemic lupus erythematosus, rheumatoid arthri own therapy more effectively. An alternative tis, and scleroderma.2 Osteoarthritis is the most approach is to use a once-a-day NSAID. Eisen common rheumatic disease and its prevalence and associates7 recently noted that patient com increases with advancing age.1,3 The progression pliance with antihypertensive medication improved of this disease may lead to severe and perma from 59% on a three-times-per-day regimen to nent physical disabilities, including the inability 84% on a once-daily regimen. Once-a-day dosing to ambulate and to carry out other activities of daily also allows the physician an almost immediate living. opportunity to evaluate both the effectiveness The primary goals in treating patients with and the tolerability of the drug. osteoarthritis are relief of pain, maintenance of joint mobility and function, and lessening of joint Precautions before initiating'NSAID therapy Dr Kirchner is a staff physician in the Department of Fam A thorough history and physical examination are ily Practice, St Joseph's Hospital, and clinical instructor, essential in identifying patients at increased risk Department of Family and Community Medicine, Lancaster for adverse reactions to NSAID treatment. This General Hospital, Lancaster, Pa. is especially true for geriatric patients who often Correspondence to Jeffrey T. Kirchner, DO, Department of Family Practice, St Joseph's Hospital, 250 College Ave, Lan have age-related reductions in renal and hepat caster, PA 17604-3509. ic function. In addition, they are more likely than 300 • JAOA • Vol 94 • No 4 • April 1994 Clinical practice • Kirchner younger patients to be receiving concomitant toms should have an initial complete blood cell medications, thus increasing the chances of drug count and a fecal occult blood test within the interactions. Also, because many older patients first month of NSAID use and every 3 to 6 are on fixed incomes, the overall cost of therapy months thereafter.10 A history of cigarette smok becomes important in NSAID selection. ing is also a significant factor in this subset of When NSAID therapy is indicated, it is pru patients because of its association with peptic ulcer dent to begin with the lowest recommended dose, disease. gradually increasing the dose as necessary over If NSAIDs are administered to geriatric a period of2 to 4 weeks.4 For the most part, low patients with established renal insufficiency, it doses of NSAIDs are analgesic and high doses are is suggested that serum sodium, potassium, anti-inflammatory. Because the type of arthri blood urea nitrogen, and creatinine levels be tis found in the majority of elderly patients is measured within 1 to 3 weeks of initiation of osteoarthritis, pain control is of more concern therapy and every 3 to 6 months thereafter.10 than reduction of inflammation. In patients at risk for hepatic toxicity-includ Patients often vary in their responsiveness to ing many elderly patients with renal insuffi various NSAIDs and, after a few weeks, anoth ciency, those using multiple drugs or alcohol on er NSAID-even withirt the same class-should a regular basis, and those receiving a high drug be tried if the ini_tial results are unsatisfactory. dose-it is recommended that initial alanine A move from one chemical class to another aminotransferase levels be monitored within such as changing from a carboxylic acid (diflunisal the first month of therapy and every 3 to 6 or aspirin) to a propionic acid (ibuprofen or months thereafter.10 oxaprozin)-may be recommended (Table 2). Some preparations are better suited to cer Although there is no good clinical evidence that tain patient profiles. One newer NSAID, etodolac, anyone NSAID is more effective than any other, is reported to have fewer gastrointestinal side some preparations may be better suited to a spe effects because of its altered metabolism. This cific patient profile.8 may be a suitable alternative in patients with a history of aspirin or NSAID-induced damage. Safety issues Administration of NSAIDs with the synthetic Gastric ulcers have been found to occur in 10% prostaglandin analogue misoprosotol has the to 15% of chronic NSAID users, and one third potential to reduce drug-induced gastric and of these patients may be asymptomatic.9 These duodenal ulcers.ll However, misoprosotol must problems increase in frequency with extended be taken four times daily, is associated with diar duration and increasing doses as well as with rhea, and compounds the overall cost of therapy. age.8,9 Acute renal failure and hepatic insult are Elderly patients receiving long-term NSAID also well-documented side effects of NSAIDs. therapy may be in danger of toxic drug accu Dermatologic reactions (Stevens-Johnson syn mulations because of a decrease in lean body drome), central nervous system disturbances mass together with reduced hepatic and renal (aseptic meningitis), hematologic conditions (neu function. An illustration of this is the systemic tropenia, aplastic anemia), and pulmonary dis clearance of oxaprozin, an NSAID recently orders (hypersensitivity pneumonitis), although approved by the Food and Drug Administration. rare, are also potential side effects.8 Some of It is considered a low-clearance drug, which these conditions have been associated with only undergoes increased systemic clearance after a few of the NSAIDs.12 Overall, the relative risk large single doses and at steady state levels.12 of adverse effects is low and should not routinely The strong binding of this drug to plasma protein dissuade clinicians from prescribing NSAIDs for a characteristic common to all NSAIDs- is their patients. decreased at the higher concentrations found If a patient is at increased risk for an adverse after a single large dose or after multiple doses event or if one should occur unexpectedly, alter when true steady-state is achieved.13 The sys native therapy such as acetaminophen or temic clearance of oxaprozin helps to limit accu propoxyphene can be used. If the reaction is not mulation of the drug.14 severe or life-threatening, a reduction in dosage or a change to another NSAID is a reasonable alter Overcoming obstacles to compliance native if t1).e therapy is carefully monitored. Physical limitations Any patient who has gastrointestinal symp- Although many older adults are in excellent gen- Clinical practice · Kirclmer JAOA • Vol 94 • No 4 • April 1994 • 301 large type.5 The directions should be explicit in Table 1 Guideline for NSAID Therapy in the Elderly terms of how many "pills" are to be taken and when one is to take them. Having the patient • Dosing repeat the medical advice and the rationale for Low dose = analgesics High dose = anti-inflammatory agents use of the prescribed medication is often help Begin with lowest recommended dose indicated ful. The patient should also be invited to ask Increase dose gradually questions and voice any concerns. Use only as much drug as necessary to provide relief Memory failure • Medication recommendations 6 Obtain a thorough medical history Elderly patients are frequently forgetful. Even Perform a thorough physical examination to aid with written directions, compliance may be dif in evaluation for risk factors ficult. It has been shown that compliance is pro Research which preparation is indicated for portional to the number of pills the patient is patient profile expected to ingest. Compliance decreases to 60% Raise and address issues of less potent over-the counter medications and warn against or less when a drug must be taken more than twice concurrent use with prescription NSAlDs daily.