An updated guideline addressing persistent pain in older people takes a tough stance on the use of non-steroidal anti-inflammatory drugs.

-Team@CMHF

• The American Geriatrics Society (AGS) guideline recommends that acetaminophen be considered for initial and ongoing treatment of persistent pain, particularly musculoskeletal pain.
• But in a significant departure from its 2002 guidelines, the AGS recommends that nonselective NSAID and cyclo-oxygenase-2 (COX-2) selective inhibitors be considered rarely, and with extreme caution, in highly selected individuals.
• The AGS had recommended that seniors use over-the-counter or prescription NSAIDs, such as aspirin or ibuprofen, or COX-2 inhibitors before being prescribed an opioid.
• The current recommendation reflects recent good evidence that this is a risky strategy in older people, panel member said at the society’s annual meeting, where the guidelines were released.
• Traditional NSAIDs are associated with adverse gastrointestinal events in 20% of patients, with 107,000 hospitalization and 16,500 deaths yearly attributed to NSAID-related GI complications.
• COX-2 inhibitors seem to produce fewer upper GI events than do other NSAIDs, but all non-steroidal, whether they are [COX-2 inhibitors] or not, have a significant portfolio of adverse effects that is noteworthy for the elderly population, the director of rheumatology at George Washington University in Washington said.
• They can aggravate hypertension, they can cause renal impairment by a variety of mechanisms, they can cause edema and gastrointestinal problems, and now we know cardiovascular and cerebrovascular disease can be attributed to non-steroidal interaction.
• A study suggested an increased risk of stroke with rofecoxib and valdecoxib, compared with the effects of nonselective agents.
• The finding was not statistically significant, but both drugs have been withdrawn from the market.
• Recent evidence also showed that combining a traditional NSAID with low-dose aspirin therapy increases the risk of GI bleeding beyond that of the traditional NSAID alone.
• The revised guideline recommends the eradication of Helicobacter pylori prior to initiating NSAIDs for pain, and the use of a proton pump inhibitor or misoprostol for gastrointestinal protection in older persons taking nonselective NSAIDs or in patients taking a COX-2 selective inhibitor with aspirin.
• The guideline recommends that physicians consider opioid therapy for patients with moderate to severe pain, pain-related functional impairment, or diminished quality of life because of pain may be treated with around-the-clock, time-contingent dosing aimed at achieving steady-state opioid therapy,
• Methadone-related deaths during treatment have risen up to eightfold in the past few years.
• Earlier this year, the American Pain Society and the American Academy of Pain Medicine released clinical guidance on the management of opioid therapy for chronic non-cancer pain.
• Like the AGS guidelines, that document stressed the need for clinicians to regularly assess patients for pain intensity, functional status, side effects, and safe and responsible medication use.
• The updated AGS guidelines also provide new references and discussions of the use and limitations of newer adjuvant, topical, and other drugs for recalcitrant pain.
• Persistent pain isn’t a normal part of aging and should not be ignored
• As seniors become susceptible to more complex health ailments, the need for a clear and precise pain management plan is key.

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