In inflammatory back pain in ankylosing spondylitis, a non-steroidal anti-inflammatory drug can better prevent radiological bone ossifications when combined with biotherapies (anti-TNF), which in theory are much more powerful.
According to the results of a study presented at the European Congress of Rheumatology (communication OP0198), patients with ankylosing spondylitis who take anti-TNFs and at the same time nonsteroidal anti-inflammatory drugs (NSAIDs) have less progression of radiological lesions than those who take only anti-TNF, and this effect is dose-dependent.
Regarding the different NSAIDs, celecoxib associated with the use of anti-TNF would be responsible for the most significant reduction in radiological progression. The difference is significant at two and four years.
Chronic inflammatory disease
Ankylosing spondylitis is a chronic inflammatory disease which is mainly responsible for lower back and back inflammatory pain, that is to say which wakes the patient up at night or in the morning. This axial disease can be associated with joint pain or arthritis (peripheral disease).
Over time, the spine can stiffen (ossify) and the joints can become damaged, a process called “radiological progression or structural progression” by doctors.
NSAIDs are the first-line treatment for patients with ankylosing spondylitis. If patients have a poor response or have contraindications or intolerance to NSAIDs, they can then receive biotherapy, and in particular TNF.
An effect of NSAIDs on the prevention of lesions
The current treatment strategy is for pain relief, but there was evidence that NSAIDs also slow radiographic progression. On the other hand, the impact of TNF inhibitors on radiographic progression is not clear despite their very good efficacy on inflammation and pain. In addition, many patients stop NSAIDs when they are on anti-TNF because of good symptom control by the latter.
“Our results suggest that the combined use of anti-TNFs and NSAIDs, in particular celecoxib, has a synergistic effect against the radiological progression of bone lesions in patients with ankylosing spondylitis, and in particular at higher doses”, explains Lianne Gensler, the study’s first author. “This is the first study to compare the effects between different NSAIDs in this context”.
A 4-year study
This prospective study included 519 patients with ankylosing spondylitis who met the modified New York criteria with at least four years of clinical and radiographic follow-up. The average age of the participants was 41.4 years with an average symptom duration of 16.8 years, three quarters were men. NSAIDs were used in 66% of patients. TNF inhibitors were used in 46% of patients.
In patients treated with anti-TNF, the addition of treatment with NSAIDs is associated with less radiological progression at four years. The mean difference in the mSASSS radiological score between anti-TNF use and no anti-TNF at four years is 0.50 (p = 0.38), -1.24 (p <0.001 ) and -3.31 (p <0.001) in the absence of combined NSAID therapy, in low-dose and high-dose NSAIDs, respectively.
A practical application
Despite their efficacy, anti-TNFs would not be sufficient to prevent radiological bone lesions and the addition of an NSAID could further reduce radiological progression. This seems logical in view of the benefits of NSAIDs already observed in this disease, on the condition, however, of taking the NSAIDs at bedtime in order to have the maximum dose of NSAIDs at night, a period when the inflammation is maximum. This would limit the doses of NSAIDs to a minimum in order to avoid the side effects of the latter.
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