What is the best Non-Steroidal Anti-Inflammatory Drug (NSAID) for Rheumatoid Arthritis (RA)?

Best NSAID for Rheumatoid Arthritis

No single NSAID is considered superior for rheumatoid arthritis; selection should be based on individual cardiovascular, gastrointestinal, and renal risk factors, with all NSAIDs used at the lowest effective dose for the shortest duration possible.

NSAID Selection in RA

NSAIDs are effective for symptomatic relief in RA but should be used cautiously due to potential side effects. The 2017 EULAR recommendations for early arthritis management clearly state that NSAIDs should be used "at the minimum effective dose for the shortest time possible, after evaluation of gastrointestinal, renal and cardiovascular risks" 1.

Key considerations when selecting an NSAID:

1. Cardiovascular risk:

   • All NSAIDs carry cardiovascular risk
   • EULAR guidelines recommend caution in prescribing NSAIDs, "especially for patients with documented CV disease or in the presence of CV risk factors" 1

2. Gastrointestinal risk:

   • Consider gastroprotective agents in high-risk patients
   • COX-2 inhibitors may have better GI safety profiles but similar cardiovascular risks

3. Renal function:

   • All NSAIDs can affect renal function
   • Regular monitoring is required in at-risk patients

4. Duration of therapy:

   • EULAR recommends following "the US Food and Drug Administration and European Medicines Agency guidelines about NSAIDs, which includes wording about the shortest possible treatment duration" 1

Specific NSAIDs in RA

While no single NSAID is recommended as superior for RA, several options are commonly used:

• Naproxen: Often considered to have a relatively balanced cardiovascular risk profile compared to other NSAIDs 2
• Ibuprofen: Commonly used but may interact with aspirin's antiplatelet function 1, 3
• COX-2 inhibitors: May have better GI tolerance but cardiovascular concerns remain

The 2017 EULAR cardiovascular disease risk management guidelines specifically state: "Prescription of NSAIDs in RA and PsA should be with caution, especially for patients with documented CVD or in the presence of CVD risk factors" 1.

Disease Management Context

It's crucial to understand that NSAIDs only provide symptomatic relief and do not modify disease progression in RA. The 2016 EULAR recommendations emphasize:

1. DMARDs are first-line therapy: "Among the DMARDs, methotrexate (MTX) is considered the anchor drug and unless contraindicated, should be part of the first treatment strategy in patients at risk of persistent disease" 1

2. NSAIDs are adjunctive therapy: They help manage pain and inflammation but don't prevent joint damage

3. Disease control is paramount: "Disease activity should be controlled optimally in order to lower CVD risk in all patients with RA" 1

Practical Approach to NSAID Selection

1. Assess individual risk factors:

   • Cardiovascular history
   • GI history (ulcers, bleeding)
   • Renal function
   • Age (higher risk in elderly)

2. Start with the safest option based on the patient's risk profile:

   • For patients with high CV risk: Consider naproxen (with gastroprotection if needed)
   • For patients with high GI risk: Consider COX-2 inhibitor or traditional NSAID with proton pump inhibitor

3. Use lowest effective dose for shortest duration possible

4. Monitor regularly for adverse effects

5. Consider NSAID-free periods when disease is well-controlled

Important Caveats

• NSAIDs may impair aspirin's antiplatelet function in patients requiring cardioprotection 1
• The role of NSAIDs in cardiovascular risk "is not well established and needs further investigation" 1
• Long-term continuous use may increase risk of heart attack or stroke 2, 3

Remember that optimal management of RA requires a treat-to-target approach focusing on disease-modifying therapy, with NSAIDs serving only as adjunctive symptomatic treatment.