What is the recommended Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) treatment for patients with scoliosis?

NSAIDs for Scoliosis Pain Management

NSAIDs are recommended as first-line drug treatment for patients with scoliosis-related pain, particularly when the pain is associated with inflammatory conditions like ankylosing spondylitis or axial spondyloarthritis. 1

First-Line Treatment Approach

• NSAIDs provide convincing evidence of improvement in spinal pain, peripheral joint pain, and function over short time periods (typically 6 weeks) in patients with inflammatory scoliosis 1
• No particular NSAID is recommended as the preferred choice, as comparative studies have not shown one preparation to be clearly better than others 1
• For patients with active inflammatory scoliosis, continuous treatment with NSAIDs may be more beneficial than on-demand treatment, as some evidence suggests continuous treatment might retard radiographic disease progression 1
• For patients with stable disease, on-demand treatment with NSAIDs is recommended over continuous treatment to minimize side effects 1

NSAID Selection Considerations

• In patients with increased gastrointestinal risk, options include:
  • Non-selective NSAIDs plus a gastroprotective agent (misoprostol, double doses of H2 blockers, or proton pump inhibitors) 1
  • Selective COX-2 inhibitors (coxibs), which have lower risk of serious GI events 1, 2
• The choice between NSAIDs or coxibs should be based on the patient's GI risk profile and concomitant cardiovascular risk factors 1, 2
• Cardiovascular toxicity appears to be a class effect of coxibs and possibly some traditional NSAIDs, requiring careful consideration in patients with cardiovascular risk factors 1

Second-Line Options

• For patients in whom NSAIDs are insufficient, contraindicated, or poorly tolerated, analgesics such as paracetamol (acetaminophen) and opioids might be considered for pain control 1, 2
• Simple analgesics have not been prospectively studied specifically for scoliosis pain management, but paracetamol has shown GI toxicity not significantly higher than placebo in other musculoskeletal conditions 1, 2

Localized Pain Treatment

• Corticosteroid injections directed to local sites of musculoskeletal inflammation may be considered for targeted pain relief, particularly for:
  • Isolated active sacroiliitis despite NSAID treatment 1
  • Active enthesitis (inflammation at tendon/ligament insertion sites) 1
  • Active peripheral arthritis 1
• Systemic glucocorticoids are strongly recommended against for long-term use in patients with inflammatory scoliosis 1

Special Considerations

• In adult scoliosis patients with chronic pain, NSAIDs may be part of a comprehensive treatment approach that includes physical therapy 3
• For patients undergoing scoliosis surgery, there is conflicting evidence regarding NSAID use in the postoperative period due to concerns about potential effects on bone healing 4
• For patients with persistently high disease activity despite NSAID treatment, biologic therapies (particularly TNF inhibitors) should be considered 1, 2

Safety Concerns

• NSAIDs carry significant side effect risks, including:
  • Serious gastrointestinal events (relative risk 5.36) 1
  • Potential cardiovascular effects, particularly with long-term use 1
  • Renal complications, especially in patients with pre-existing kidney disease 2
• Regular monitoring of patients on long-term NSAID therapy is essential to detect potential adverse effects early 1