Update of the Use of Nonsteroidal Anti-inflammatory Drugs in Patients with Ankylosing Spondylitis
In 2015 the American College of Rheumatology, the Spondylitis Association of America, and the Spondyloarthritis Research and Treatment Network published recommendations for the treatment of Ankylosing Spondylitis (AS) and an early form of the illness designated Non-radiographic Axial Spondyloarthritis. The recommendations listed a number of non-drug and drug therapies effective in the treatment of ankylosing spondylitis.1
Nonsteroidal drugs (NSAIDs) are a large class of agents including ibuprofen, naproxen, diclofenac, celecoxib, among others. These drugs have common characteristics. They decrease fever, pain, and inflammation. These drugs are also associated with an increased risk of gastrointestinal bleeding and high blood pressure that may lead to stroke or heart attack. The authors strongly recommend treatment of active AS patients with NSAIDs. The group also recommended continuous daily use versus an as needed course of treatment. Although a number of NSAIDs have been shown to be better than placebo, no particular NSAID is currently recommended over another. Each individual will need to find the specific drug that is most effective without causing side effects.
In light of the new recommendations, should an individual with active AS take a NSAID and for what reason?
Individuals with AS have an increased risk of cardiovascular events like heart attack or strokes thought to be related to increased damage to blood vessels because of ongoing systemic inflammation. In this setting, are NSAIDs worth taking?
Haroon and colleagues reported on a large study from Ontario, Canada, studying the risk of heart attack and stroke in 21,473 AS patients compared to 86,606 without AS. Vascular events were more common in AS individuals, occurring 25% more frequently in those with AS compared to controls.2 When the authors looked at individuals with AS who were aged 66 or older who are those most at risk of vascular event they found that the use of NSAIDs was associated with a decreased risk of vascular events compared to those who did not take NSAIDs. This suggests that control of AS inflammation with NSAIDs may have an overall benefit compared to the risk of increased blood pressure causing risk for vascular events in individuals who reach an older age.
- Ward W, Deodhar A, Akl E, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. American College of Rheumatology. DOI 10.1002/ART.39298
- Haroon N, Paterson J, Li P, et al. Patients with ankylosing spondylitis have increased cardiovascular and cerebrovascular mortality. Ann Intern Med 2015:163:409-416.