A patient with osteoarthritis and a known gastric ulcer presents with joint pain. Which of the following analgesics is most appropriate for pain relief?

1. A

   Etoricoxib

2. B

   Naproxen

3. C

   Ibuprofen

4. D

   Diclofenac

Appeared in: NORCET 9 Mains - 2025

Explanation

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• Etoricoxib is a selective COX-2 inhibitor, designed to target inflammation and pain while minimizing harm to the stomach lining.
• By selectively blocking the COX-2 enzyme, it reduces the production of inflammatory prostaglandins at the site of pain (the joints in osteoarthritis).
• Crucially, it spares the COX-1 enzyme, which is responsible for producing protective prostaglandins in the gastrointestinal tract.
• This selective action makes it the safest option among the choices for a patient with a known gastric ulcer, as it significantly lowers the risk of ulcer exacerbation or GI bleeding compared to non-selective NSAIDs.

Why Other Options Were Wrong

• Option B: Naproxen is a non-selective NSAID, meaning it inhibits both COX-1 and COX-2. Inhibiting COX-1 disrupts the protective lining of the stomach, posing a high risk of worsening the patient's existing gastric ulcer or causing a severe GI bleed.
• Option C: Ibuprofen is a classic non-selective NSAID that inhibits both COX-1 and COX-2. Its use is strongly discouraged in patients with a history of gastric ulcers due to the high risk of causing or exacerbating GI bleeding.
• Option D: Diclofenac is a non-selective NSAID, although it shows some preference for COX-2 over COX-1 compared to ibuprofen. However, this selectivity is not sufficient to make it safe for a patient with a known gastric ulcer, as it still carries a significant risk of GI toxicity.

Related Visual

• Visual 1: Diagram - Illustrate the mechanism of action of NSAIDs. Show two pathways: one for non-selective NSAIDs blocking both COX-1 (stomach lining) and COX-2 (inflammation), and another for selective COX-2 inhibitors blocking only COX-2, leaving COX-1 active.
• Visual 2: Chart - A risk-stratification chart showing which analgesics are preferred based on a patient's GI and cardiovascular risk profile. This would place the current patient in the 'High GI Risk, Low CV Risk' quadrant, pointing towards a COX-2 inhibitor.

Clinical Relevance

• Nursing practice connection: Use the key finding related to Pharmacological management of pain in patients with high gastrointestinal risk to guide bedside assessment, documentation, and the next nursing action.
• A nurse's primary responsibility includes medication safety. This involves reviewing patient history for contraindications, such as a gastric ulcer, before administering medications like NSAIDs.
• Patient education is critical. The nurse must teach the patient to recognize signs of GI bleeding (e.g., black, tarry stools; coffee-ground vomit; abdominal pain) and to report them immediately.
• What if? If the patient had a high cardiovascular risk (e.g., a history of heart attack) but no GI risk, the choice might change. In that scenario, Naproxen is often considered a safer NSAID than selective COX-2 inhibitors, which have been associated with a higher risk of cardiovascular events.

How to Approach the Question

• First, identify the key elements of the clinical scenario: The patient has osteoarthritis (needs pain relief) and a known gastric ulcer (a major safety concern).
• The question asks for the 'most appropriate' drug, which signals that you must balance efficacy with safety.
• Categorize the medication options. Recognize that Etoricoxib is a selective COX-2 inhibitor, while Naproxen, Ibuprofen, and Diclofenac are non-selective NSAIDs.
• Recall the mechanism of action for each category. Non-selective NSAIDs block COX-1 (protective for the stomach) and COX-2 (inflammation). Selective inhibitors primarily block COX-2.
• Apply this knowledge to the patient's specific risk factor. The gastric ulcer makes protecting the stomach (a COX-1 function) the top priority.
• Conclude that the drug that spares COX-1 (the selective COX-2 inhibitor, Etoricoxib) is the most appropriate and safest choice.

Concept Tested & Keywords

• Concept Tested: Pharmacological management of pain in patients with high gastrointestinal risk.
• Stem keywords: osteoarthritis, gastric ulcer, joint pain, analgesics
• Lead-in keywords: most appropriate
• Clinical cues: Patient has two competing conditions: osteoarthritis requiring pain relief (often NSAIDs) and a gastric ulcer, which is a contraindication for many traditional NSAIDs.

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