When are NSAIDs appropriate in osteoarthritis?
Clinical Pharmacology Unit, Chapel Allerton Hospital, Leeds, England.
Osteoarthritis is a multifactorial disease that is more common in the elderly than in younger individuals. Opinion is divided on whether it is a degenerative or inflammatory process. Most rheumatologists accept that the disease has an inflammatory component, particularly when it is complicated by crystal deposition. Nonsteroidal anti-inflammatory drugs (NSAIDs) are particularly toxic in the elderly. The geriatrician should use a more conservative approach to initial therapy, which should include patient education, physiotherapy and even the consideration of intra-articular steroid injections. If systemic drug therapy is still required, simple analgesics should usually be tried first. If NSAIDs are then required, they can be selected according to their chemical structure (which bears some relation to adverse effects) or half-life (which is more relevant to optimum prescribing). Propionic acid derivatives are well established and remain the NSAIDs of choice: agents with a short half-life, perhaps given in low dosages, are preferred. The use of topical formulations, which are more expensive, may avoid some adverse effects; however, drug effects are unlikely to remain truly localised. It may be prudent to provide gastroprotective therapy for some elderly patients. A full evaluation of the new generation of cyclooxygenase-2 inhibitors in osteoarthritis is still awaited.
Oesophageal mucosal diseases in the elderly.
Ouatu-Lascar R. Triadafilopoulos G.
Gastroenterology Section, Palo Alto Veterans Affairs Health Care System, California, USA.
Diseases of the oesophageal mucosa are particularly prevalent in the elderly population and may present with various symptoms, such as heartburn, dysphagia or chest pain. Recent technological advances, such as endoscopy, ambulatory pH monitoring and radiological imaging, have allowed for a more accurate diagnosis and assessment of disease severity. Depending on the leading presenting symptom, empirical medical therapy or stepwise diagnostic tests may be used. Elderly patients with mild reflux symptoms respond well to over-the-counter antacids, acid suppressants or prescription prokinetic drugs. Those with more severe gastrooesophageal reflux disease and Barrett's oesophagus benefit from powerful acid suppressive therapy to relieve symptoms, heal the mucosal damage and prevent complications. Long term, cost-effective pharmacological therapies are constantly being defined. Because of the widespread utilisation of medications in the elderly, drug-induced oesophageal injury should always be considered and prevented. An increasing number of immunocompromised elderly patients are diagnosed and successfully treated for infectious oesophagitis. Overall, for most elderly patients, when the diagnosis is made correctly, modern medical and/or surgical treatments yield maximal therapeutic benefit and improve quality of life.