A 53-year-old seamstress comes to the physician with pain and intermittent swelling in her fingers for the past 3 years. Symptoms involve primarily the distal interphalangeal joints and occur after she sews. A year ago, she was hospitalized with upper gastrointestinal bleeding and was found to have erosive gastritis and a duodenal ulcer. Her other medical problems include hypertension, type 2 diabetes mellitus, and fatty liver. Her current medications are glipizide, sitagliptin, lisinopril, and amlodipine.
Her blood pressure is 133/70 mm Hg and pulse is 78/min. Her BMI is 26 kg/m². Her hands appear as shown below. There is bony swelling and tenderness of several distal interphalangeal joints. The remainder of the examination is within normal limits.

Laboratory results are as follows:

Liver function tests are within normal limits.
Which of the following is the most appropriate treatment for this patient?

Question

A 53-year-old seamstress comes to the physician with pain and intermittent swelling in her fingers for the past 3 years. Symptoms involve primarily the distal interphalangeal joints and occur after she sews. A year ago, she was hospitalized with upper gastrointestinal bleeding and was found to have erosive gastritis and a duodenal ulcer. Her other medical problems include hypertension, type 2 diabetes mellitus, and fatty liver. Her current medications are glipizide, sitagliptin, lisinopril, and amlodipine.
Her blood pressure is 133/70 mm Hg and pulse is 78/min. Her BMI is 26 kg/m². Her hands appear as shown below. There is bony swelling and tenderness of several distal interphalangeal joints. The remainder of the examination is within normal limits.

Laboratory results are as follows:

Liver function tests are within normal limits.
Which of the following is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

This patient's presentation is consistent with osteoarthritis of the hands. She has a history of GI bleed and should avoid NSAIDs. A COX-2-specific NSAID (eg, celecoxib) may reduce the risk of GI bleed but has the same nephrotoxicity risk as a nonspecific NSAID. Since this patient has renal insufficiency, she should avoid all NSAIDs if possible (Choices C and E). Acetaminophen is the safest choice for this patient. Even in patients with advanced liver disease, tramadol and acetaminophen are safer than NSAIDs. (Choice B) Adalimumab (Humira), an anti-TNF antibody, is used in the treatment of rheumatoid arthritis or spondylarthritis. It is not indicated for the treatment of osteoarthritis. (Choice D) Methotrexate is indicated for treatment of rheumatoid arthritis. However, the absence of pain or swelling of the PIP or MCP joints makes rheumatoid arthritis unlikely in this patient. Psoriatic arthritis is also treated with methotrexate. However, this patient's occupation and lack of skin findings make psoriasis unlikely. Educational objective: Acetaminophen is preferred for osteoarthritis in patients with kidney disease or at risk of peptic ulcer disease. COX-2-specific NSAIDs are equally nephrotoxic and offer no advantage over traditional NSAIDs in patients with renal impairment. __________ References: Celecoxib plus aspirin versus naproxen and lansoprazole plus aspirin: a randomized, double-blind, endoscopic trial. (http://www.ncbi.nlm.nih.gov/pubmed/17916545) Pharmacological therapies for osteoarthritis of the hand: a review of the evidence. (http://www.ncbi.nlm.nih.gov/pubmed/20809663) Renal failure associated with the use of celecoxib and rofecoxib (http://www.ncbi.nlm.nih.gov/pubmed/12093311)

A 53-Year-Old Seamstress Comes to the Physician with Pain and Intermittent