Advanced Studies inMedicine I S519

PRESENTATION
Ruth is a healthy and active 59-year-old retired
executive secretary who suffers from daily joint stiff-
ness and pain with minimal exertion. Acetaminophen
4 g daily provides only partial relief from pain and
stiffness, leaving her unable to participate in the phys-
ical activities she enjoys.
MEDICAL HISTORY
Aside from an appendectomy at age 26 years, Ruths
medical history is unremarkable. Her current medica-
tionsare vitamin D and a calcium supplement.
PHYSICAL EXAMINATION
Ruth is 5 ft, 5 in tall and weighs 132 lb. Her vital
signs and auscultatory findings are normal. Her bowel
sounds are normal. Palpation of the abdomen reveals it
to be soft, nontender, and negative for organomegaly.
A rectal exam for occult blood is negative.
Physical examination of the spinal column and the
tissues surrounding the shoulder and elbow joints and
the joints of the hands and feet is normal. However,
the knees, lower back, and the hip joints are painful
when Ruth is asked to rise from a sitting position or to
bend over and straighten up.
LABORATORY FINDINGS
Standard blood chemistry and lipid profile values
are within the normal range. Radiography of the
knees, hips, and lower back reveals irregular joint space
narrowing and slightly increased radiologic density of
subchondral bone, signs that are consistent with a
diagnosis of osteoarthritis.
TREATMENT
Because Ruth has none of the established risk fac-
tors for GI complications of NSAIDs, ibuprofen 600
mg 3 times daily is recommended as initial therapy.
She is instructed to report any GI symptoms.
DISCUSSION
For a patient such as Ruth, who has little or no risk
for GI complications and does not use aspirin chroni-
cally or require it for cardioprotection, monotherapy
with a traditional nonselective NSAID is a reasonable
initial approach to reducing the pain and inflamma-
tion of osteoarthritis.
Cyclooxygenase-2 (COX-2) selective inhibitors, or
coxibs, which are as effective as traditional NSAIDs
and cause fewer adverse GI events in patients at low GI
risk, are also an option. However, COX-2 selective
CASE STUDY 1
A H EA LTH Y 59-YEA R-O LD W O M A N W ITH O STEO A RTH RITIS

Linda A . Lee, M D
*
CONTEXT
This case study represents the upper left quadrant
of the 2 x 2 risk stratification/ therapy selection matrix
described in the interview with A. Mark Fendrick, MD
(see Figure, page S516). The patient is at no risk/ low
risk for gastrointestinal (GI) complications related to
the use of nonsteroidal anti-inflammatory drugs
(NSAIDs) and does not use or require aspirin prophy-
laxis to protect against cardiovascular events.
* A ssistant Professor of M edicine, D ivision of
G astroenterology, Johns H opkins U niversity School of
M edicine, Baltim ore, M aryland.
S520 Vol. 3 (6B) I June 2003
CASE STUDY
inhibitors are more expensive than aspirin and other
traditional NSAIDs. Moreover, cost-effectiveness
analyses reveal that COX-2 inhibitors yield relatively
poor value in these patients.
1
Therefore, it is phar-
macoeconomics that precludes the routine prescrip-
tion of safer COX-2 inhibitors as initial therapy for
low-risk patients.
2
If cost were not a consideration,
therapy for low-risk patients would begin with a
COX-2 inhibitor rather than a traditional NSAID.
If Ruth developsGI symptomswhile taking a tradi-
tional NSAID for osteoarthritis, an antacid or an antise-
cretory agent, such asa proton pump inhibitor (PPI) or
an H
2
-receptor antagonist should be added to the regi-
men. Although all of these agentsare effective in treating
dyspepsia, only misoprostol and PPIssuch asomeprazole
and lansoprazole have been shown to heal and prevent
recurrence of NSAID-induced ulcersat standard doses.
2
REFERENCES
1. Fendrick AM , Bandekar RR, C hernew M E, Scheim an JM .
Role of initial N SAID choice and patient risk factors in the
prevention of N SAID gastropathy: a decision analysis.
Arthritis Rheum . 2002;47:36-43.
2. Fendrick AM , G arabedian-Ruffalo SM . A clinicians guide
to the selection of N SAID therapy. Pharm Ther. 2002;
27:579-581, 582.