Question 2#

A 78-year-old woman with mild renal insufficiency complains of pain in the right knee on walking. The pain interferes with her day-to-day activities and is relieved by rest. There is no redness or swelling. There is minimal joint effusion. An x-ray of the knee shows osteophytes and asymmetric loss of joint space. ESR and white blood cell count are normal.

Which of the following is the best initial management of this patient? 

a. Naproxen
b. Indomethacin
c. Intra-articular corticosteroids
d. Acetaminophen
e. Total knee arthroplasty

Correct Answer is D


This patient has osteoarthritis. In addition to physical therapy, the best symptomatic treatment would be acetaminophen because it is frequently effective in providing pain relief and has an excellent safety profile in the elderly. Nonsteroidals should be avoided, at least initially, because they tend to cause gastrointestinal upset and impairment of renal function. Indomethacin is relatively contraindicated in the elderly because of its long half-life and central nervous system side effects. Intra-articular steroids are indicated for large effusions in joints unresponsive to first-line therapy. Arthroplasty is highly effective in treating osteoarthritis of a single joint and is not contraindicated in the elderly. Such surgery is usually considered if attempts at physical therapy, education, and pain control with pharmacotherapy do not provide adequate symptom relief.