Question
A previously healthy 63-year-old man comes to the physician because of bilateral knee pain for the past year. The pain is worse with movement and is relieved with rest. Physical examination shows crepitus, pain, and decreased range of motion with flexion and extension of both knees. There is no warmth, redness, or swelling. X-rays of both knees show irregular joint space narrowing, osteophytes, and subchondral cysts. Which of the following is the most appropriate pharmacotherapy?
| A. |
Prednisone
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| B. |
Methotrexate
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| C. |
Naproxen
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| D. |
Allopurinol
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Show Answer
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Correct Answer � C
Explanation
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|
Ans-C-Naproxen
Prednisone
Oral prednisone can be used to treat inflammatory arthritis, such as rheumatoid arthritis. This patient lacks any signs of inflammatory arthritis (e.g., erythema, warmth of the affected joint), and the chronicity and bilateral nature of his symptoms make osteoarthritis much more likely. In patients with severe pain due to osteoarthritis, intra-articular glucocorticoids can be used but the systemic administration of glucocorticoids is not recommended.
Methotrexate
Methotrexate is a DMARD that reduces inflammation, prevents joint destruction, and slows disease progression in individuals with rheumatoid arthritis. This patient’s history and x-ray findings (subchondral cysts, osteophytes, and joint space narrowing) suggest osteoarthritis, not rheumatoid arthritis. Because osteoarthritis is not an inflammatory process, methotrexate would have no therapeutic benefit.
Naproxen
NSAIDs such as naproxen are used as first-line pharmacotherapy for patients with osteoarthritis. Because of the degenerative nature of osteoarthritis, management should be focused on treating pain as well as maintaining and improving joint mobility and function. Other medications used for the treatment of osteoarthritis include acetaminophen, topical capsaicin, and intra-articular glucocorticoids. Glucocorticoid injections are usually only indicated for acute, severe pain in which NSAIDs have not been effective.
Allopurinol
Allopurinol is a reversible xanthine oxidase inhibitor that prevents the conversion of hypoxanthine and xanthine into uric acid. Allopurinol is used as a maintenance therapy for patients with gout, which is associated with hyperuricemia and typically has an acute presentation with asymmetric joint swelling and pain (classically affecting the big toe). This man’s subacute and bilateral symptoms are consistent with osteoarthritis, for which allopurinol is not effective.
