NSAIDs atop TNFi may reduce radiographic progression in AS
Patients with ankylosing spondylitis (AS) derived a greater benefit from tumour necrosis factor (TNF) inhibitors in terms of less radiographic progression when they also took non-steroidal anti-inflammatory drugs (NSAIDs), suggests a cohort study presented at the EULAR 2018 Congress.
“Our results suggest that the use of TNF inhibitors and NSAIDs, particularly celecoxib, have a synergistic effect to slow radiographic progression in AS patients, particularly at higher doses,” said lead author Dr Lianne Gensler of the University of California, San Francisco in in San Francisco, California, US.
The prospective cohort study involved 519 patients (mean age 41.4 years, 75 percent male) with AS based on the modified New York criteria who were followed up on clinical (every 6 months) and radiographic measures (every 2 years) for at least 4 years. Two-thirds of the patients used NSAIDs and 46 percent of patients used TNF inhibitors. The analysis was adjusted for sex, race/ethnicity, duration of TNF inhibitor use, symptom duration, baseline mSASSS*, ASDAS-CRP**, education level, current smoking, enrolment year, and missed visit status. [EULAR 2018, abstract OP0198]
Compared with patients not treated with TNF inhibitors, TNF inhibitor users had a significantly slower radiographic progression at 4 years when they also took NSAIDs. Also, the association appeared to be dose-dependent — the higher the intake of NSAIDs, the lesser the radiographic progression was, as scored using the mSASSS: 0.50; p=0.38 for nonuse, -1.24; p<0.001 for low NSAID intake, and -3.31; p<0.001 for high NSAID intake.
When the analysis was stratified by the type of NSAID used, celecoxib use was associated with the greatest reduction in radiographic progression with TNF inhibitor vs nonuse of TNF inhibitor (mean difference in mSASSS, -3.98; p<0.001 and -4.69; p<0.001 for 2 and 4 years, respectively).
“Celecoxib appears to confer the greatest benefit in decreasing progression with [significant] effect at both 2 and 4 years,” said Landewé.
The first-line treatment for AS is NSAIDs. Patients may be given TNF inhibitors if there are contraindications, poor response, or intolerance to NSAIDs. [Ann Rheum Dis 2017;76:978-991] Previous study has suggested that NSAIDS may slow radiographic progression in AS patients if taken continuously. [Arthritis Rheum 2005;52:1756-1765] However, many patients discontinued NSAIDs after achieving good symptom control with TNF inhibitors. [Arthritis Res Ther 2014;16:481] Hence, data were limited regarding the impact on radiographic progression with combined therapy.
Radiographic progression has important implications on a patient’s mobility and general well-being, according to Professor Robert Landewé, Chairperson of the Scientific Programme Committee of EULAR. “We welcome these results that support a potential disease modifying effect in patients with AS taking current therapies.”