Limited Efficacy of NSAIDs in Spondyloarthritis

Jack Cush, MD

Jan 31, 2017 12:57 pm

Prior to the biologic era, nonsteroidal antiinflammatory drugs (NSAIDs) were the mainstay of drug therapy in thos with spondyloarthritis (SpA) and ankylosing spondylitis (AS). Their role in the modern era has changed and the claims for efficacy have varied.

Baraliakos and colleagues have studied the utility of NSAIDs are first-line therapy in axial SpA (axSpA) and non-radiographic axSpA (nr-axSpA) patients.

Fifty patients anti-TNF-naïve patients with either nr-axSpA and AS were included if their BASDAI score was ⩾4 without having received maximal NSAID doses.

An NSAID was prescribed and for the next 3 weeks, continuous intake of maximal doses was recommended but patients could reduce doses in case of intolerance or improvement. MRI of the SI joints was performed at baseline and week 4.

All outcomes except for CRP and MRI scores improved significantly after 4 weeks of NSAIDs, with no difference between axSpA subgroups. The Assessment of SpondyloArthritis international Society 40% (ASAS40) response and partial remission rates were 35 and 16% at week 4, respectively.

However, a BASDAI score ⩾4 was still present in 44% of patients, 30% of which had reduced NSAID doses, partly due to intolerance (38%).

Only 13% of all patients had continuously taken NSAIDs at the maximal dosage, but there was no clinical difference compared with those who had taken reduced doses.

Although NSAIDs improve clinical responses in AS and nr-axSpA patients, there was no change in inflammatory markers or MRI over 4 weeks. Thus there appeas to be limited efficacy for NSAIDs in SpA patients, as only 13% could take maximal doses of NSAIDs, and ⩾40% patients remained candidates for TNF blockers.

Efficiency of treatment with non-steroidal anti-inflammatory drugs according to current recommendations in patients with radiogr

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Since I was a Radiology Resident I have been convinced that the major cause of back pain is arthrosis of the posterior facet joints which are in fact very similar to wear and tear with age and activity in the IP and MP joints of the digits. I am also convinced that most Radiologists pay no attention to this area and focus instead on the condition of discs which may be involved with invisible herniation or on the other hand non-symptomatic even when extremely degenerated. I recall that the Chief of Neurosurgery at the hospital I served served called me to the OR to demonstrate how I had awakened him to the importance of this area which he usually bypassed in his routine surgery. This consideration may be extremely more important in the age of overdoses of pain drugs when a correct diagnosis is not made at the beginning.

This is an astute observation and analogy well appreciated by most rheumatologists. Recognition is paramount, but then comes the inevitability of trying to treat structural painful damage with limited options - agents are ineffective, potentially hazardous and poorly perceived by the public and press. Narcotics are clearly not the answer. Lifestyle, physical therapy, local management need to be addressed. Above all we need better treatment options. Great contribution!! thanks. JC

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The author has no conflicts of interest to disclose related to this subject