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NSAID nephrotoxicity — USMLE Step 3 MCQ

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HardInternal Medicine (Chronic Management)NSAID nephrotoxicityUSMLE Step 3

A 76-year-old woman with stage 3b chronic kidney disease, apixaban-treated atrial fibrillation, and symptomatic knee osteoarthritis has pain despite acetaminophen and a supervised exercise program. There is no effusion or inflammatory morning stiffness. She wishes to avoid injections. Which next treatment offers the best balance of efficacy and systemic safety?

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Correct answer: E — Add topical diclofenac to the ongoing exercise program

The best answer is “Add topical diclofenac to the ongoing exercise program”. For knee osteoarthritis, topical NSAIDs provide local analgesic benefit with substantially less systemic exposure than oral NSAIDs. That distinction matters with CKD and anticoagulation. Exercise remains core therapy. Duloxetine can be considered later, but stopping exercise is inappropriate; chronic opioids or glucocorticoids have unfavorable risk-benefit profiles, and gastroprotection does not remove oral NSAID renal and bleeding risk.

Reference: American College of Rheumatology Osteoarthritis Guideline: https://rheumatology.org/osteoarthritis-guideline