Anti-Inflammatory Drugs

ANTI-INFLAMMATORY DRUGS

Osteoarthritis is a very common disease of the elderly. Rheumatoid arthritis is less exclusively a geriatric problem, but the same drug therapy is usually applicable.

The nonsteroidal anti-inflammatory agents (NSAIDs) must be used with special care in geriatric patients because they cause tox-icities to which the elderly are very susceptible. In the case of aspi-rin, the most important of these is gastrointestinal irritation and bleeding. In the case of the newer NSAIDs, the most important is renal damage, which may be irreversible. Because they are cleared primarily by the kidneys, these drugs accumulate more rapidly in the geriatric patient and especially in the patient whose renal func-tion is already compromised beyond the average range for his or her age. A vicious circle is easily set up in which cumulation of the NSAID causes more renal damage, which causes more cumula-tion. There is no evidence that the cyclooxygenase (COX)-2 selec-tive NSAIDs are safer with regard to renal function. Elderly patients receiving high doses of any NSAID should be carefully monitored for changes in renal function.

Corticosteroids are extremely useful in elderly patients who cannot tolerate full doses of NSAIDs. However, they consistently cause a dose- and duration-related increase in osteoporosis, an especially hazardous toxic effect in the elderly. It is not certain whether this drug-induced effect can be reduced by increased calcium and vitamin D intake, but it would be prudent to con-sider these agents (and bisphosphonates if osteoporosis is already present) and to encourage frequent exercise in any patient taking corticosteroids.