Nonsteroidal Antiinflammatory Drug Use and Association With Incident Hypertension in Ankylosing Spondylitis

Efficacy and safety of iguratimod combined with celecoxib in active axial spondyloarthritis: a randomized, double-blind, placebo-controlled study

OBJECTIVE

To assess the efficacy and safety of iguratimod in adult patients with active axial spondyloarthritis (axSpA).

METHOD

This randomized, double-blind, placebo-controlled clinical trial lasted for 28 weeks. Patients with axSpA were randomized 1:1 to receive iguratimod 25 mg twice daily or a placebo. All patients also took celecoxib 200 mg twice daily for the first 4 weeks and on demand from 4 to 28 weeks. The primary endpoints were ASAS20 at 4 weeks and the non-steroidal anti-inflammatory drug (NSAID) index at 28 weeks. Other assessment variables included ASAS40, ASAS5/6 response rates, Spondyloarthritis Research Consortium of Canada (SPARCC) scores, and adverse events.

RESULTS

In total, 35 patients completed the study and were included for analyses. The median (interquartile range) NSAID index was 43.8 (34.9-51.8) in the iguratimod group, which is significantly lower than 68.9 (42.5-86.4) in the placebo group (p = 0.025). ASAS response rates and changes in disease activity scores were similar between the iguratimod and placebo groups. Patients in the iguratimod group had more improvement in median (interquartile range) SPARCC scores for sacroiliac joints than did those in the placebo group [71% (54-100%) vs 40% (0-52%), p = 0.006]. Iguratimod combined with celecoxib was not associated with a greater risk of adverse effects than was monotherapy with celecoxib. No severe adverse events occurred.

CONCLUSIONS

In the treatment of active axSpA, iguratimod has a potential NSAID-sparing effect, and may also reduce magnetic resonance imaging-assessed bone marrow oedema in sacroiliac joints. Iguratimod provides an additional treatment option for patients with active axSpA.Clinical trial registration numberChiCTR2000029112, Chinese Clinical Trial Registry (http://www.chictr.org.cn).

Risk of cardiovascular disease with high-dose versus low-dose use of non-steroidal anti-inflammatory drugs in ankylosing spondylitis

OBJECTIVE

To investigate the risk of cardiovascular disease (CVD) associated with increasing dose of a non-steroidal anti-inflammatory drug (NSAID) in patients with ankylosing spondylitis (AS).

METHODS

Using the Korean National Health Insurance database, patients newly diagnosed with AS without prior CVD between 2010 and 2018 were included in this nationwide cohort study. The primary outcome was CVD, a composite outcome of ischaemic heart disease, stroke or congestive heart failure. Exposure to NSAIDs was evaluated using a time-varying approach. The dose of NSAIDs was considered in each exposure period. Cox proportional hazard regression was used to investigate the risk of CVD associated with NSAID use.

RESULTS

Of the 19 775 patients (mean age, 36 years; 75% were male), 19 706 received NSAID treatment. During follow-up period of 98 290 person-years, 1663 cases of CVD occurred including 1157 cases of ischaemic heart disease, 301 cases of stroke and 613 cases of congestive heart failure. Increasing dose of NSAIDs was associated with incident CVD after adjusting for confounders (adjusted HR (aHR) 1.10; 95% CI 1.08 to 1.13). Specifically, increasing dose of NSAIDs was associated with incident ischaemic heart disease (aHR 1.08; 95% CI 1.05 to 1.11), stroke (aHR 1.09; 95% CI 1.04 to 1.15) and congestive heart failure (aHR 1.12; 95% CI 1.08 to 1.16). The association between NSAID dose and higher CVD risk was consistent in different subgroups.

CONCLUSION

In a real-world AS cohort, higher dose of NSAID treatment was associated with a higher risk of CVD, including ischaemic heart disease, stroke and congestive heart failure.

Cardiovascular disease in spondyloarthritis: a narrative review of risk factors and the effect of treatments

PURPOSE OF REVIEW

This review summarizes the recent evidence available regarding the epidemiology of cardiovascular disease in spondyloarthritis (SpA), including the effect of disease modifying drugs on cardiovascular risk.

RECENT FINDINGS

People with SpA suffer from an increased risk of cardiovascular disease compared to the general population. This elevated risk is explained by the high prevalence of traditional cardiovascular risk factors and inflammation from disease activity leading to endothelial dysfunction and accelerated atherosclerosis. Consequently, the American College of Cardiology/American Heart Association and the European League Against Rheumatism recommend enhanced cardiovascular risk screening in SpA patients. There is evidence from observational studies that methotrexate and tumor necrosis factor inhibitors reduce the risk of cardiovascular events in SpA. Unlike what is observed in the general population, the use of nonsteroidal anti-inflammatory drugs does not appear to increase cardiovascular disease risk in SpA.

SUMMARY

Cardiovascular diseases are increasingly recognized in patients suffering from SpA, especially axial SpA and psoriatic arthritis. Cardiovascular diseases can cause significant morbidity, mortality, and add to the overall disease burden. Disease modifying drugs may mitigate some of the cardiovascular risk; however, a multidisciplinary team is needed to monitor patients and improve cardiovascular health status.

Inflammation is associated with incident hypertension in patients with axial spondyloarthritis: A longitudinal cohort study

OBJECTIVES

To elucidate the risk factors for the development of incident hypertension (IHT) in patients with axial spondyloarthritis (axSpA).

METHODS

We conducted a retrospective cohort study in axSpA patients who were recruited from 2001 to 2019 from a university clinic in Hong Kong. Patients with HT and/or anti-hypertensive drug use at baseline were excluded. They were followed until the end of 2020. The outcome was IHT, defined by a diagnosis and a prescription for an antihypertensive drug. Baseline and time-varying Cox regression analyses adjusting for age, sex, and body mass index (BMI), were used to assess the relationship between drug use, inflammatory burden, and IHT.

RESULTS

Four hundred and thirteen patients [age: 34(25-43) years, male: 319 (77.2%)] were recruited. After a median follow-up of 12 (6-17) years, 58 patients (14%) developed IHT (IHT+group). Among all the baseline variables, disease duration and delay in diagnosis were the independent predictors for IHT based on the Cox regression model. In the multivariate Cox regression analysis, baseline disease duration, delay in diagnosis and time-varying ESR levels were independent predictors associated with an increased risk of IHT. IHT risk was significantly increased in patients with disease duration >5 years. The use of anti-inflammatory drugs was not associated with the development of IHT.

CONCLUSION

Higher inflammatory burden as reflected by a longer disease duration, delay diagnosis and higher ESR levels, were predictors associated with IHT after adjusting for traditional CV risk factors. These data support routine screening for hypertension in axSpA patients, especially those with longer disease duration.

The association between comorbidities and disease activity in spondyloarthritis - A narrative review

Comorbidities, including cardiovascular disease, osteoporosis, and depression, are more prevalent in patients with spondyloarthritis (SpA) than in the general population. Clinical and laboratory markers of disease activity are associated with numerous of these comorbidities, and studies suggest that the treatment of SpA can have a positive impact on comorbidities; conversely, managing comorbidities can improve disease activity. Therefore, the screening of comorbidities is considered a core component of a rheumatology consultation, and treatment should be performed in liaison with other health professionals (e.g. general physicians). Validated tools and questionnaires can be used for not only the detection but also the monitoring of potential comorbidities. Understanding whether a comorbidity is a separate disease entity, linked to SpA or its treatment, or an extra-musculoskeletal manifestation of the disease is important to identify the most appropriate treatment options.

Development and Validation of a Self-Administered Questionnaire Measuring Essential Knowledge in Patients With Axial Spondyloarthritis

OBJECTIVE

To develop and validate a patient knowledge questionnaire regarding axial spondyloarthritis (axSpA).

METHODS

Knowledge considered essential for patients with axSpA was identified through Delphi rounds among rheumatologists, healthcare professionals (HCPs), and patients, then reformulated to develop the knowledge questionnaire. Cross-sectional validation was performed in 14 rheumatology departments to assess internal validity (Kuder-Richardson coefficient), external validity, acceptability, reproducibility (Lin concordance correlation coefficient), and sensitivity to change (knowledge score before vs after patient education sessions and effect size).

RESULTS

The Spondyloarthritis Knowledge Questionnaire (SPAKE) is a self-administered 42-item questionnaire with a 32-item short form, both scored 0 to 100, assessing knowledge of disease, comorbidities, pharmacological treatments, nonpharmacological treatments, self-care, and adaptive skills. In the validation study (130 patients; 67 [51.5%] male, mean age 43.5 [SD 12.9] yrs), the mean (SD) score of the long-form questionnaire was 71.6 (15.4), with higher scores (better knowledge) in nonpharmacological treatments and adaptive skills and lower scores in cardiovascular comorbidity and pharmacological treatments. Acceptability was good, with no missing data; the internal validity coefficient was 0.85. Reproducibility was good (0.81, 95% CI 0.72-0.89). SPAKE showed good sensitivity to change; scores were 69.2 (15.3) then 82.7 (14.0) after patient education sessions (Hedges effect size = 0.92, 95% CI 0.52-1.31).

CONCLUSION

SPAKE is a knowledge questionnaire for patients with axSpA, developed with the involvement of HCPs and patients and reflecting current recommendations for the management of axSpA. SPAKE will be useful in assessing knowledge acquisition and self-management strategies in routine care and research.

Nonsteroidal anti-inflammatory drugs and cardiovascular disease risk in spondyloarthritis-spectrum diseases

PURPOSE OF REVIEW

Increased cardiovascular (CV) risk associated with nonsteroidal anti-inflammatory drugs (NSAIDs) is well recognized in the general population. This may limit the use of this effective therapy in patients with spondyloarthritis (SpA), a population already at high CV risk.

RECENT FINDINGS

Increased CV diseases and their risk factors in patients with SpA were consistently shown in recent population-level data. NSAIDs remained commonly prescribed in SpA, though their structural benefit remained controversial and the dispensing practice was variable in different regions in the world. A previous observation study suggested NSAIDs in SpA might be cardio-protective, possibly via their modulation of the chronic inflammatory state. A recent meta-analysis of nonrandomized studies also revealed no increased risk of a CV event. Interestingly, there is growing evidence that different NSAIDs might impose differential CV risk on patients with SpA.

SUMMARY

Recent evidence suggested NSAIDs were associated with a neutral and possibly lower CV risk in patients with SpA, which provided some reassurance for their use.

Treatment of axial spondyloarthritis: an update

Diagnosis and management of axial spondyloarthritis (axSpA) has vastly improved over the past two decades. With advances in the discernment of immunopathogenesis of this disease, new therapies have become available, which are associated with substantial improvement in symptoms, signs and quality of life. The four broad categories of approved treatment options are physical therapy and exercise (which have been known to be beneficial for millennia), NSAIDs (since the 1950s), TNF inhibitors (first FDA approval in 2003) and IL-17 inhibitors (first FDA approval in 2016). In addition, there have been a host of new developments in the axSpA field, including new treatment guidelines, the FDA approval of three biologic DMARDs to treat non-radiographic axSpA, the FDA and EMA approval of Janus kinase (JAK) inhibitors for ankylosing spondylitis, new data on the effect of biologic DMARDs on structural progression in ankylosing spondylitis, strategy trials on tapering or stopping TNF inhibitors in patients in remission, trials of treat-to-target strategy in axSpA, and several new molecules in phase III studies. This Review explores the developments in the management of axSpA.

Prevalence of non-steroidal anti-inflammatory drugs (NSAIDs) use in patients with hypertensive crisis

BACKGOUND

One of the known risk factors for hypertensive crisis (HTN-C) is non-steroidal anti-inflammatory drugs (NSAIDs) which their adverse effects can lead to end-organ damage such as gastrointestinal and cardiovascular issues.

AIMS

Data on the correlation between NSAIDs and HTN-C are limited. In this study, we determined the prevalence of NSAID use among patients with HTN-C.

MATERIALS & METHODS

This cross-sectional study was conducted among patients primarily diagnosed with HTN-C referred to Alzahra hospital, Shiraz, Iran from April 2015 to April 2020. Demographic data, as well as information regarding the past medical and drug history and laboratory findings, were gathered retrospectively. The history of NSAID use was also asked specifically. The collected data were analyzed by SPSS and the P-value less than .05 was considered significant.

RESULTS

A total of 257 patients with a mean age of 59.73 were enrolled in the study. Among them 62.6% were female and 137 patients (53.33%) used NSAIDs. Of all the patients 197 (76.7%), 71 (27.6%), and 46 (17.9%) suffered from concomitant hypertension (HTN), diabetes mellitus (DM), and ischemic heart disease (IHD) respectively. A significant relation was found between having each of the comorbidities and NSAIDs use among HTN-C patients (P-value <.0001). NSAIDs use was also significantly higher in older age (P-value <.0001) and female gender (P-value <.02). A high rate of NSAID use was seen among HTN-C patients with a positive significant correlation to concomitant diseases, older age, and female gender.

CONCLUSION

The Results of our study indicate that NSAIDs are frequently used among those with HTN-C and considering the adverse effects of these medication our results further highlight the importance of monitoring and limiting NSAID use.

2022 French Society for Rheumatology (SFR) recommendations on the everyday management of patients with spondyloarthritis, including psoriatic arthritis

OBJECTIVE

Update the French Society for Rheumatology (SFR) recommendations on the everyday management of patients with spondyloarthritis, including psoriatic arthritis.

METHODS

Following standardized procedures, a systematic literature review was done by four supervised rheumatology residents based on questions defined by a task force of 16 attending rheumatologists. The findings were reviewed during three working meetings that culminated in each recommendation receiving a grade and the level of agreement among experts being determined.

RESULTS

Five general principles and 15 recommendations were developed. They take into account pharmacological and non-pharmacological measures along with treatment methods based on the dominant phenotype present (axial, articular, enthesitis/dactylitis) and the extra-articular manifestations (psoriasis, inflammatory bowel disease, uveitis). NSAIDs are the first-line pharmacological treatment in the various presentations. Conventional synthetic disease modifying antirheumatic drugs (csDMARDs) are not indicated in the axial and isolated entheseal forms. If the response to conventional treatment is not adequate, targeted therapies (biologics, synthetics) should be considered; the indications depend on the clinical phenotype and presence of extra-articular manifestations.

CONCLUSION

This update incorporates recent data (published since the prior update in 2018) and the predominant clinical phenotype concept. It aims to help physicians with the everyday management of patients affected by spondyloarthritis, including psoriatic arthritis.

Acute myocardial infarction in a young man with ankylosing spondylitis: A case report

BACKGROUND

Ankylosing spondylitis (AS) is a chronic progressive inflammatory disease that mainly affects the spine and sacroiliac joints. To the best of our knowledge, AS with acute myocardial infarction (AMI) has rarely been reported. Here, we report an unusual case of AS with AMI in a young patient.

CASE SUMMARY

A 37-year-old man was admitted to the Department of Rheumatology and Immunology of our hospital on March 14, 2020, for low back pain. Further evaluation with clinical examinations, laboratory tests, and imaging resulted in a diagnosis of AS. Treatment with a non-steroidal anti-inflammatory drug and a tumor necrosis factor inhibitor partially improved his symptoms. However, his back pain persisted. After 6 wk of treatment, he was admitted to the emergency room of another hospital in this city for sudden-onset severe chest pain consistent with a diagnosis of AMI. Angiography revealed severe narrowing of the coronary arteries. Surgical placement of two coronary stents completely relieved his back pain.

CONCLUSION

AS can cause cardiovascular diseases, including AMI. It is important to consider the cardiovascular risks in the management of AS.

The Risk of Cardiovascular Diseases in Axial Spondyloarthritis. Current Insights

There is an increased cardiovascular (CV) risk in axial spondyloarthritis (axSpA), leading to increased CV mortality and morbidity in these patients. The factors that may explain this enhanced CV risk in axSpA are multiple, including traditional CV risk factors such as smoking, but also the inflammatory process and probably the use of non-steroidal anti-inflammatory drugs (NSAIDs). The CV involvement of axSpA may be detected at an early and pre-clinical stage, using non-invasive techniques. While NSAIDs play a deleterious role in the CV risk of axSpA, TNF inhibitors seem to have a beneficial impact, but this remains to be demonstrated in specific clinical studies. More data are needed to determine the potential effects of IL-17 inhibitors on the CV risk of axSpA. CV comorbidity has been mainly assessed in the radiographic form of axSpA, while limited data are available in patients with the non-radiographic form. The current management of axSpA must consider this CV comorbidity according to the EULAR recommendations. Rheumatologists play a determinant role in the detection of CV risk and current management of these patients is focused on the control of disease activity, suppression of inflammation, screening for and management of traditional CV risk factors, as well as the restriction of NSAID use.

The Association of Tumor Necrosis Factor Inhibitor Use With Incident Hypertension in Ankylosing Spondylitis: Data From the PSOAS Cohort

OBJECTIVE

Individuals with ankylosing spondylitis (AS) have a greater cardiovascular (CV) risk than those in the general population. The effect of tumor necrosis factor inhibitors (TNFis) on CV risk, including on the development of hypertension (HTN), remains unclear, with some data suggesting higher risk. We assessed the association of TNFi use with incident HTN in a longitudinal AS cohort.

METHODS

Adults with AS enrolled in a prospective cohort in 2002-2018 were examined every 4-6 months. TNFi use during the preceding 6 months was ascertained at each study visit. We defined HTN by patient-reported HTN, antihypertensive medication use, or, on 2 consecutive visits, systolic blood pressure (BP) ≥ 140 mmHg or diastolic BP ≥ 90 mmHg. We evaluated the association between TNFi use and the development of HTN with marginal structural models, estimated by inverse probability-of-treatment weighting, to account for time-dependent confounders and informative censoring. Potential confounders included age, sex, race, site, nonsteroidal antiinflammatory drug use, and disease activity.

RESULTS

We included 630 patients without baseline HTN and with at least 1 year of follow-up. Of these, 72% were male, mean age was 39 ± 13 years, and 43% used TNFi at baseline. On follow-up (median 5 yrs), 129 developed incident HTN and 163 started on TNFi during follow-up. TNFi use was not associated with incident HTN (adjusted HR 1.10, 95% CI 0.83-1.37).

CONCLUSION

In our prospective AS cohort, TNFi use was not significantly associated with incident HTN.

NSAIDs erhöhen Risiko für Bluthochdruck bei AS-Patienten

Patienten mit ankylosierender Spondylitis (AS) haben ein erhöhtes Risiko für kardiovaskuläre Erkrankungen. Aktuelle Leitlinien empfehlen nichtsteroidale Antirheumatika (NSAIDs) als First-Line Therapie der AS, Studien zeigen jedoch, dass NSAIDs den Blutdruck erhöhen können. Liew et al untersuchten die Assoziation einer NSAID-Therapie mit der Entwicklung einer Hypertonie in einer großen prospektiven Beobachtungskohorte von AS-Patienten.

Efficacy and safety of warm acupuncture in the treatment of ankylosing spondylitis: A protocol for systematic review and meta-analysis

BACKGROUND

Ankylosing spondylitis refers to a type of autoimmune disease, which is commonly characterized by joint pain and stiffness, since the disease progression can exhibit joint deformity and other activities limited symptoms. Has significantly impacts on people's work and life. Warm acupuncture as a traditional Chinese therapy, showing several advantages (eg, safety, economy, and less side effects), has been extensively used to treat ankylosing spondylitis. However, its curative effect is supported by limited evidence. Accordingly, the present study aims to comprehensively assess the reliability of warm acupuncture in ankylosing spondylitis treatment.

METHODS

Randomized controlled trials were searched from the Chinese Biomedical Literature Database, Chongqing VIP Database for Chinese Technical Periodicals, China National Knowledge Infrastructure, Wanfang, Web of Science, Cochrane Library, PubMed, and EMBASE, regardless of their publication status. The deadline was November 6th, 2020. Two experienced researchers adopted RevMan V.5.3 software for literature selection, data collection, data analysis, and synthesis, respectively. In addition, the quality of the trials involved in this study was measured with the Cochrane Bias risk assessment tool, regardless of language or publication status.

RESULTS

The protocol will be used to assess the efficacy and safety of warm acupuncture in ankylosing spondylitis treatment.

CONCLUSION

This review reliably evidences whether warm acupuncture is a reliable method for the intervention of ankylosing spondylitis.

INPLASY REGISTRATION NUMBER

INPLASY2020110096.