A Cochrane review [Abstract] 1 of the effect of non-steroidal anti-inflammatory drugs (NSAIDs) for people with axial spondyloarthritis (axSpA) included 39 studies (35 RCTs, 2 quasi-RCTs and 2 cohort studies) of which 29 RCTs and two quasi-RCTs (n = 4 356) were included in quantitative analyses.
Traditional NSAIDs (table T1) and COX-2 NSAIDs (table T2) were more efficacious than placebo in the outcomes of pain, disease activity and functional capacity, and did not lead to more withdrawals due to adverse events (AEs), or increase in the number of serious AEs. When looking at the number of adverse events per organ system, there were more gastro-intestinal adverse events (RR 1.92, 95% CI 1.41 to 2.61; 5 studies, n=1 289) and fewer neurological adverse events (including headache and dizziness) (RR 0.44, 95% CI 0.24 to 0.82; 4 studies, n=1 144) in patients taking traditional NSAIDs compared to placebo. In patients taking COX-2 NSAIDs, there were more gastro-intestinal adverse events compared to placebo (RR 1.80, 95% CI 1.22 to 2.67; 3 studies, n=669), and in the other organ systems that were assessed (respiratory, neurological and dermatological) there was no difference in the number of adverse events.
| Outcome | Follow-up | Relative effect(95% CI) | Assumed risk - placebo | Corresponding risk - traditional NSAID (95% CI) | Participants (studies) |
|---|---|---|---|---|---|
| Pain on VASScale from 0 to 100 mm (higher is worse) | 2 to 6 weeks | The mean pain score in the control group was61 points | The mean pain scores in the intervention groups was 16.5 points lower (12.2 to 20.8 lower) | 850 (4 studies) | |
| BASDAIScale from 0 to 100 (higher is worse) | 6 weeks | The mean BASDAI in the control group was54.7 points | The mean BASDAI in the intervention group was17.5 points lower (11.8 to 23.1 lower) | 190 (1 study) | |
| BASFIScale from 0 to 100 (higher is worse) | 6 weeks | The mean BASFI in the control groups was50.0 points | The mean BASFI in the intervention groups was9.1 points lower (5.1 to 13.0 lower) | 356 (2 studies) | |
| Withdrawals due to adverse events | 2 to 12 weeks | RR 0.75 (0.46 to 1.21) | 52 per 1000 | 39 per 1000 (24 to 63) | 1 165 (5 studies) |
| Number of serious adverse events | 6 to 12 weeks | RR 1.69 (0.36 to 7.97) | 2 per 1000 | 3 per 1000(1 to 16) | 671 (3 studies) |
| BASDAI = Bath Ankylosing Spondylitis Disease Activity Index; BASFI = Bath Ankylosing Spondylitis Functional Index | ||||||||||||||||||||||||||||||||||||
There were no significant differences in benefits or harms between traditional NSAID and COX-2 NSAID classes. Single studies suggested NSAIDs may be effective in retarding radiographic progression of the spine in axSpA, especially in certain subgroups of patients, e.g. patients with high CRP, and that this may be best achieved by continuous rather than on-demand use of NSAIDs.
COX-2 NSAIDs compared with placebo
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| BASDAI = Bath Ankylosing Spondylitis Disease Activity Index; BASFI = Bath Ankylosing Spondylitis Functional Index | ||||||||||||||||||||||||||||||||||||
Clinical comments
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