CASE STUDY 1
A HEALTHY 59-YEAR-OLD WOMAN WITH OSTEOARTHRITIS
—
Linda A. Lee, MD*
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.
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, Ruth’s
medical history is unremarkable. Her current medica-
tions are 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
*Assistant Professor of Medicine, Division of
Gastroenterology, Johns Hopkins University School of
Medicine, Baltimore, Maryland.
Advanced Studies in Medicine ■ S519
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
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 develops GI symptoms while taking a tradi-
tional NSAID for osteoarthritis, an antacid or an antise-
cretory agent, such as a proton pump inhibitor (PPI) or
an H2-receptor antagonist should be added to the regi-
S520
men. Although all of these agents are effective in treating
dyspepsia, only misoprostol and PPIs such as omeprazole
and lansoprazole have been shown to heal and prevent
recurrence of NSAID-induced ulcers at standard doses.2
REFERENCES
1. Fendrick AM, Bandekar RR, Chernew ME, Scheiman JM.
Role of initial NSAID choice and patient risk factors in the
prevention of NSAID gastropathy: a decision analysis.
Arthritis Rheum. 2002;47:36-43.
2. Fendrick AM, Garabedian-Ruffalo SM. A clinician’s guide
to the selection of NSAID therapy. Pharm Ther. 2002;
27:579-581, 582.
Vol. 3 (6B) ■ June 2003