A 65-year-old man comes to the office due to intermittent right knee pain for the last 3 or 4 months. The symptoms are worse at the end of the day, and he has had mild swelling at the knee following strenuous exertion. There is no associated fever, malaise, or rash. The patient takes metformin for type 2 diabetes mellitus. BMI is 36 kg/m². On examination, the right knee has bony enlargement and a small effusion but no warmth or erythema. Range of motion elicits pain. Analysis of synovial fluid obtained via arthrocentesis shows a leukocyte count of 1,800/mm³ with no crystals. Serum creatinine is 0.8 mg/dL and serum uric acid is 5.6 mg/dL. In addition to a supervised exercise program, which of the following medications is the most appropriate for relief of this patient's symptoms?

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11ec25c8_d2bf_e126_bc81_0b922f758e45_MD0003_00 This patient has chronic joint pain, periarticular bony enlargement, and a bland synovial effusion (ie, low synovial leukocyte count, no crystals), findings consistent with osteoarthritis (OA). Risk factors include advancing age, obesity, diabetes, and prior joint injury. Patients typically have no or only mild inflammatory features (eg, erythema, morning stiffness, systemic symptoms). Examination can show crepitus and, sometimes, a small effusion. The diagnosis can be confirmed with x-ray, which reveals narrowed joint space, osteophytes, and possible subchondral sclerosis. x-ray Initial management of OA should emphasize nonpharmacologic measures, including exercise, weight loss, and activity modification. Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, diclofenac) are the medication of choice for OA pain relief and can be given in oral or topical form. NSAIDs should be used with caution in patients with a history of peptic ulcer, coronary artery disease, or chronic kidney disease (CKD). Although diabetes is a risk factor for CKD, this patient has normal renal function, so use of NSAIDs is appropriate. (Choice A) The combination of acetaminophen and opioids (eg, oxycodone) is not recommended as first-line therapy for OA given the associated risks (eg, dependence and sedation with opioids, gastrointestinal toxicity with acetaminophen). (Choices B and D) Febuxostat is a xanthine oxidase inhibitor used in management of chronic gout. Colchicine is used in both prevention and treatment of acute gout flares. Gout is characterized by intermittent inflammatory arthritis; synovial fluid shows many leukocytes (eg, 2,000-100,000/mm³), as well as needle-shaped, negatively birefringent crystals. (Choice E) When conservative measures fail, patients with OA can be considered for an intraarticular glucocorticoid injection, although the benefits are limited and these injections may promote further joint damage. Oral glucocorticoids (eg, prednisone) are used in rheumatoid arthritis and other inflammatory arthropathies but not in OA. Educational objective: The initial management of osteoarthritis should emphasize nonpharmacologic measures, including exercise, weight loss, and activity modification. Nonsteroidal anti-inflammatory drugs are the medication of choice for pain relief.

A 65-Year-Old Man Comes to the Office Due to Intermittent