MKSAP: 67-year-old woman who takes diclofenac

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

A 67-year-old woman is evaluated during a routine examination. She has a history of hip and knee pain related to degenerative joint disease. The joint pain is now well controlled with diclofenac, which was started 3 months ago. A previous trial of high-dose acetaminophen was not effective. She does not have any gastrointestinal symptoms, and she takes the diclofenac with food most of the time. Her medical history is otherwise notable for type 2 diabetes mellitus, hyperlipidemia, and hypertension. Her parents both had coronary artery disease. Her medications are low-dose aspirin, metformin, chlorthalidone, simvastatin, and diclofenac.

On physical examination, vital signs are normal. Abdominal examination is unremarkable.

Which of the following is the most appropriate management?

A. Change to enteric-coated aspirin
B. Continue the current medication regimen
C. Initiate omeprazole, 20 mg once daily
D. Initiate omeprazole, 40 mg once daily

MKSAP Answer and Critique

The correct answer is C: Initiate omeprazole, 20 mg once daily.

The most appropriate management is to start standard-dose omeprazole (20 mg/d). The chronic use of NSAIDs is associated with significant gastrointestinal risk. Nearly one in four chronic NSAID users will develop ulcer disease and as many as 4% will have bleeding or perforation complications. Risk factors for NSAID-related gastrointestinal complications include a history of peptic ulcer disease or other gastrointestinal bleeding event; Helicobacter pylori infection; age 65 years or older; concomitant use of aspirin (of any dose), anticoagulants, other NSAIDs, or glucocorticoids; high-dose NSAID use; and chronic comorbid illness. Although this patient is currently tolerating her daily NSAID well, she has several risk factors that put her at increased risk for NSAID-associated gastric injury (age older than 65 years and daily low-dose aspirin for cardiovascular risk reduction). Therefore, the most appropriate strategy for gastric protection is omeprazole, 20 mg/d. Standard-dose daily proton pump inhibitor (PPI) therapy has consistently demonstrated superiority to placebo in significantly reducing the risk of NSAID-induced gastric injury. Higher PPI doses have not demonstrated superiority to standard-dose therapy. If PPI therapy cannot be used, misoprostol, 200 µg four times daily, is an alternative; however, side effects such as abdominal cramps and diarrhea may be limiting.

Changing this patient’s aspirin to an enteric-coated formulation will not reduce the risk of NSAID-induced gastrointestinal injury.

Given this patient’s risk profile, preventive measures should be pursued. Therefore, continued observation alone on the current medication regimen is not appropriate.

Key Point

  • Standard-dose daily proton pump inhibitor therapy significantly reduces the risk of NSAID-induced gastric injury.

This content is excerpted from MKSAP 17 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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