Case-Based Approach for the Management of Rheumatic Diseases - Episode 3

Treatment Strategy and the Role of NSAIDS

May 26, 2020

Transcript: Sergio Schwartzman, MD: What is the treatment strategy in patients who have nonradiographic axial spondyloarthritis? It should really be the same as what we use in ankylosing spondylitis. So a critical element is the nonpharmacological components. In that regard, exercise is important, stretching is very important, and patients should do this every day. Nonsteroidal anti-inflammatory agents are a critical group of medications that are useful in this disease group, as well. And generally, as therapies are implemented to manage these patients, the first approach is to try nonsteroidal anti-inflammatory agents in conjunction with the nonpharmacological components that I’ve mentioned.

If that does not result in success, then biologic therapy should be utilized. And to that point, our current guidelines from a number of societies do recommend that anti-TNF agents should be utilized first in this group of patients. However, there are a number of different types of biologics that have now been approved for the management of patients with axial spondyloarthritis. Only 1 has been approved for nonradiographic axial spondyloarthritis in the United States and that is certolizumab.

In terms of other therapies that are available and utilized to manage these patients, there has not been a great amount of success. I would make a strong argument against the use of opioids, for example, and the DMARD [disease-modifying antirheumatic drugs] group of medications, things like methotrexate, for example, or leflunomide, have not been effective in this group of diseases. Corticosteroids should not be used over the long term, and there may be a role for episodic use of these medications during disease flares or as intra-articular injections, if there are peripheral joint symptoms. Some people have actually utilized direct sacroiliac joint injections; however, this treatment does not usually result in efficacy over the long term.

In terms of nonsteroidal anti-inflammatory agents, these medications have been utilized to manage patients with axial spondyloarthritis for many years—before we even used that term when we were calling all of these patients—ankylosing spondylitis. And these medications are effective in treating some of these patients.

In fact, there are data that have been published, mostly old data, now, that have looked at prevention of radiographic progression in patients with ankylosing spondylitis or are managed with nonsteroidal anti-inflammatory agents alone. And that has shown some efficacy. So a trial of at least 1, but generally 2, nonsteroidal anti-inflammatory agents for several months is appropriate. However, as our patient care exemplifies, these medications over the long term can result in significant adverse effects such as GI [gastrointestinal] toxicity in our patients.

Transcript Edited for Clarity