Is it safe to continue daily Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for 1 year in an Ankylosing Spondylitis (AS) patient?

NSAIDs in Ankylosing Spondylitis: Continuous Treatment for One Year

Continuous NSAID treatment for one year is conditionally recommended for patients with persistently active ankylosing spondylitis, but on-demand treatment is preferred for patients with stable disease, with careful monitoring of cardiovascular, gastrointestinal, and renal risks. 1

NSAID Treatment Strategy Based on Disease Activity

For Active Ankylosing Spondylitis:

• NSAIDs are strongly recommended as first-line drug treatment for pain and stiffness 1
• Continuous treatment with NSAIDs is conditionally recommended for patients with persistently active, symptomatic disease 1
• No particular NSAID is recommended as the preferred choice based on efficacy 1, 2
• Consider selective COX-2 inhibitors in patients at high risk for serious adverse events 1, 3

For Stable Ankylosing Spondylitis:

• On-demand treatment with NSAIDs is conditionally recommended over continuous treatment 1
• Continuous NSAID treatment in clinically stable patients might only be considered for those with early AS, no comorbidities, and higher propensity to develop progressive spinal fusion (men, smokers, persistently high CRP, existing syndesmophytes) 1

Monitoring During Long-term NSAID Treatment

• Regular monitoring of cardiovascular, gastrointestinal, and renal parameters is essential during continuous NSAID therapy 1, 3
• Regular-interval monitoring of disease activity using validated measures (ASDAS, BASDAI) and inflammatory markers (CRP, ESR) is conditionally recommended 1
• Frequency of monitoring should be individualized based on disease course, severity, and treatment 1
• Spinal radiographs should not be repeated more frequently than every 2 years unless clearly indicated 1

Potential Benefits of Continuous NSAID Treatment

• Continuous NSAID therapy may reduce radiographic progression compared to on-demand treatment 4
• However, evidence regarding continuous vs. on-demand treatment effect on structural progression is inconsistent 1
• The panel suggests continuous use of NSAIDs in active axSpA only to control symptoms, not to attempt to control progression of structural damage 1

Risks and Considerations

• Cardiovascular risks: Monitor for hypertension and other cardiovascular complications 1, 3
• Gastrointestinal risks: Watch for abdominal pain, dyspepsia, and other GI symptoms 3, 5
• Renal risks: Regular monitoring of renal function is necessary 1, 3
• Approximately 25% of patients report severe side effects from NSAID treatment, most commonly abdominal pain, headache, dizziness, and nausea 5
• The percentage of patients changing NSAIDs due to side effects ranges from 10.5% to 31.4% depending on the specific NSAID 5

Alternative Approaches

• If NSAIDs are insufficient or contraindicated, consider anti-TNF therapy for patients with persistently high disease activity 1
• There is no evidence to support the obligatory use of DMARDs before or concomitant with anti-TNF therapy in patients with axial disease 1
• Analgesics such as paracetamol and opioid-like drugs might be considered for residual pain after NSAIDs have failed, are contraindicated, or poorly tolerated 1

Important Caveats

• NSAID failure should be considered after 1 month of continuous use (at least two NSAIDs for 15 days each) 1
• Response rates to full-dose NSAIDs according to ASAS20 criteria may be as low as 29.5% in patients with active ankylosing spondylitis 6
• Younger patients with shorter disease duration may respond better to NSAID therapy 6
• Anti-TNF therapy may reduce the need for intensive long-term NSAID therapy in AS 5