A 76-year-old woman comes to the physician for routine follow-up. She complains of frequent right knee pain and swelling that is relieved by daily naproxen. She was offered knee replacement surgery for her severe osteoarthritis, but she refused. She was diagnosed with stable angina five years ago and has not undergone any coronary intervention. She denies chest pain with mild exertion, but admits to occasional chest discomfort with moderate exertion.
Her other medical problems include atrial fibrillation, hypertension, hyperlipidemia, and diet-controlled type 2 diabetes mellitus. Her current medications include warfarin with target INR 2-3, low-dose aspirin, metoprolol, enalapril, and rosuvastatin. She is an ex-smoker with a 35 pack-year smoking history.
Her blood pressure is 130/69 mm Hg and pulse is 80/min and irregular. Her BMI is 42 kg/m². A 2/6 mid-systolic murmur is heard at the left sternal border. Her lungs are clear. The right knee is mildly swollen and tender.
Laboratory results are as follows:

Which of the following additional medications would most likely benefit the patient?

Question

A 76-year-old woman comes to the physician for routine follow-up. She complains of frequent right knee pain and swelling that is relieved by daily naproxen. She was offered knee replacement surgery for her severe osteoarthritis, but she refused. She was diagnosed with stable angina five years ago and has not undergone any coronary intervention. She denies chest pain with mild exertion, but admits to occasional chest discomfort with moderate exertion.
Her other medical problems include atrial fibrillation, hypertension, hyperlipidemia, and diet-controlled type 2 diabetes mellitus. Her current medications include warfarin with target INR 2-3, low-dose aspirin, metoprolol, enalapril, and rosuvastatin. She is an ex-smoker with a 35 pack-year smoking history.
Her blood pressure is 130/69 mm Hg and pulse is 80/min and irregular. Her BMI is 42 kg/m². A 2/6 mid-systolic murmur is heard at the left sternal border. Her lungs are clear. The right knee is mildly swollen and tender.
Laboratory results are as follows:

Which of the following additional medications would most likely benefit the patient?

Quizplus · Accepted Answer

11ec193a_97f5_d2e2_853d_a76ee84fac00_MD0002_00 Non-steroidal anti-inflammatory drugs (NSAIDs) cause significant morbidity and mortality due to gastrointestinal (GI) toxicity, particularly in elderly patients. This patient has multiple risk factors for NSAID-associated GI toxicity. Current guidelines recommend switching high or moderate risk patients to a selective COX-2 inhibitor or combining NSAIDs with a PPI or misoprostol. Lansoprazole is approved in the U.S. for prevention of NSAID-induced ulcers. Additionally, patients should take the lowest possible dose of NSAIDs. This high risk patient should be placed on prophylaxis, since she will likely require long-term NSAIDs for osteoarthritis. (Choice A) The patient is on therapeutic doses of warfarin (goal INR 2-3) plus aspirin without embolic phenomena from atrial fibrillation. Adding clopidogrel would not reduce her embolization risk and it could significantly increase her bleeding risk. (Choice B) The patient's LDL cholesterol is below the recommended goal of < 70 mg/dL with the use of a statin alone. Adding a fibrate would not benefit the patient and would increase the risk of statin myopathy. (Choice C) Elderly diabetics with multiple comorbidities have a recommended target HbA1c of 7.0-7.9%, rather than the commonly used goal of < 7.0% in younger patients. A HbA1c < 7.0% can increase the risk of hypoglycemic events in elderly patients, which further increases the risk of adverse cardiac events and cognitive impairment. Giving this patient glyburide would decrease her HbA1c of 7.2% and increase hypoglycemia risk. (Choice E) Niacin raises HDL but it has a higher side effect profile and lower cardiac benefit in a 76-year-old patient with optimal LDL and stable medical conditions. Educational objective: Patients taking chronic NSAIDs at high or moderate risk for GI toxicity should be switched to either a selective COX-2 inhibitor or be given a PPI or misoprostol in combination with the NSAID. __________ References: Clinical efficacy of esomeprazole in the prevention and healing of gastrointestinal toxicity associated with NSAIDs in elderly patients. (http://www.ncbi.nlm.nih.gov/pubmed/18331072) NSAID-associated adverse effects and acid control aids to prevent them: a review of current treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/16454539)

A 76-Year-Old Woman Comes to the Physician for Routine Follow-Up