An updated guideline addressing persistent pain in older people takes a tough stance on the use of nonsteroidal anti-inflammatory drugs.
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 nonsteroidals, 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 nonsteroidal interaction.”
Last year’s study of 336,906 community-dwelling Medicaid beneficiaries by the Veterans Affairs Tennessee Valley Healthcare System extended concerns about COX-2 selective inhibitors to cerebrovascular disease. The 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 The finding was not statistically significant, but both drugs have been withdrawn from the market.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. In 2006, the Food and Drug Administration warned against taking aspirin and ibuprofen together because ibuprofen interferes with aspirin’s acetylation effect.
More research is needed to determine whether other NSAIDs interfere with the cardioprotective benefits of low-dose aspirin.
Panel members also said that more data are needed on the safety of topical preparations of NSAIDs.
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, said the pain management center at the University of Utah, Salt Lake City.
He noted the guideline’s caution concerning methadone, and recommended that only clinicians who are well versed in its use and risks initiate and titrate the drug. “That doesn’t mean you don’t do it,” “but hook yourself up to someone who has a lot of experience in this when you believe this drug is indicated, if you don’t already have the experience.”
Methadone-related deaths during treatment have risen up to eightfold in the past few years. This is largely because methadone is attractive as a relatively inexpensive drug, but it has an unpredictable and long half-life. That the drug stays active is a blessing, but is also a problem because it accumulates in the body.
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 noncancer 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 provides 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,” AGS president said in a statement. “As seniors become susceptible to more complex health ailments, the need for a clear and precise pain management plan is key.”
The AGS published its first pain guideline in 1998. To arrive at the 2009 recommendations, a panel of experts conducted a systematic review of 2,400 abstracts and 240 data-based, full-text articles. The panel focused on pharmacotherapy because it is the most common strategy used for pain management among elderly people, as well as the area of greatest risk, said the University of California, Los Angeles, who chaired the panel.
The 2009 update is to be published in an upcoming issue of the Journal of the American Geriatrics Society.