MKSAP: 64-year-old man with knee osteoarthritis

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 64-year-old man is evaluated for a 2-year history of knee osteoarthritis. He has bilateral knee pain that worsens with walking. He has tried topical therapies, physical therapy, and acetaminophen, none of which has provided relief. The patient also has peripheral vascular disease, hyperlipidemia, and hypertension. Medications are hydrochlorothiazide, pravastatin, and a daily aspirin.

On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 116/76 mm Hg, pulse rate is 60/min, and respiration rate is 12/min. BMI is 26. Musculoskeletal examination reveals small knee effusions bilaterally, with crepitus and tenderness along the medial joint line.

Laboratory studies, including complete blood count, erythrocyte sedimentation rate, plasma glucose, and serum creatinine, are normal.

Radiographs of the knees, including weight-bearing studies, reveal bilateral medial joint-space narrowing, subchondral sclerosis, and small osteophytes.

Which of the following is the most appropriate treatment for this patient?

A: Celecoxib
B: Colchicine
C: Indomethacin
D: Prednisone
E: Tramadol

MKSAP Answer and Critique

The correct answer is E: Tramadol.

Treatment with tramadol is indicated for this patient with knee osteoarthritis. Acetaminophen is first-line pharmacologic therapy for osteoarthritis because of its safe profile at approved doses, and it is considered complementary to nonpharmacologic interventions. However, this patient has not responded to acetaminophen in conjunction with physical therapy and topical therapies. Tramadol is a multi-acting agent, and its use in patients with osteoarthritis is well established. This partial opiate agonist also raises serotonin and norepinephrine levels; unlike most opiates, its addictive potential is low, and it does not cause constipation.

Selective cyclooxygenase-2 inhibitors such as celecoxib are useful in the treatment of osteoarthritis but are associated with increased cardiovascular risk in susceptible persons such as this patient who has peripheral vascular disease, hyperlipidemia, and hypertension.

Colchicine has potent anti-inflammatory effects in specific diseases such as gout and familial Mediterranean fever; however, it carries no analgesic potential and is not used to treat osteoarthritis.

Indomethacin is a potent nonselective NSAID with anti-inflammatory effects. Because of its numerous side effects, this agent is not considered first-line therapy in the management of a chronic condition such as osteoarthritis. Its strong association with induction of hypertension and kidney disease makes indomethacin a less desirable agent for this patient. Additionally, indomethacin and most other nonselective NSAIDs are associated with varying degrees of cardiovascular risk and should be employed with caution, especially in high-risk patients. One exception may be naproxen, which in epidemiologic studies has been associated with a lower level of cardiovascular risk and possibly even cardioprotection.

Although corticosteroid injections into the knees may have transient benefit in patients with osteoarthritis, oral prednisone is not standard for osteoarthritis and lacks the analgesic capacity of NSAIDs.

Key Point

  • Selective cyclooxygenase-2 inhibitors are associated with increased cardiovascular risk and should be used cautiously in patients with cardiovascular disease.

This content is excerpted from MKSAP 16 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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  • Thomas D Guastavino

    You can’t be serious. You do realize that you may be committing this patient to taking tramadol for the rest of his life. Aspiration and CS injections are the clear and obvious next step. Although it is true that relief may be short lived it is also possible that this patient could be pain free for a considerable period of time, in some cases, years. Even if short lived hyaluoronic acid injections could be tried next. The minimal systemic exposure to this patient with a number of co-morbidities is also a big plus.

    • Suzi Q 38

      Thank you, doctor.

      I am wondering what to do with my own knee, as I am an active 58 year old female who likes to keep active. I am not sitting around and watching TV. I exercise everyday.

      I have tried one treatment of aspiration, and the fluid around the knee just returned soon after. maybe I will ask my orthopedic surgeon or rheumatologist about the CS injections.

      More than twenty years ago, I had heal spurs that were very painful. They came as the direct result of playing soccer (I played on teams from the ages of 16 through 42). I received one injection in the heal of a steroid when I was about 35, and the pain never returned. I have not needed another injection since.

  • Suzi Q 38

    Thank you, doctor.

  • RenegadeRN

    I thought they were trying to get Tramadol removed from the market?
    Also, I can report a former co-worker was absolutely addicted to Tramadol, despite the IM doc at our hospital denying it had addictive properties. There was repeated drug seeking behaviors directed at all RNs with any access. I am not a fan of this drug.

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