NSAIDs

This information is for anyone with axial spondyloarthritis, including people with ankylosing spondylitis

Non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of axial SpA management

When you are diagnosed with axial SpA  you will usually be offered an NSAID as a starting point. NSAIDs help reduce the pain and stiffness caused by inflammation. They can be used in addition to simple painkillers such as paracetamol.

There are many different NSAIDs available in the UK. Some commonly used NSAIDs include ibuprofen, naproxen and diclofenac. Many are available to buy over the counter but stronger NSAIDs are only available on prescription.

The coxibs, or COX-2-specific NSAIDs, are a group of drugs that also reduce inflammation, but they are less likely than standard NSAIDs to cause stomach upsets, heartburn and indigestion. Some commonly used coxibs in the UK include celecoxib (Celebrex) and etoricoxib (Arcoxia).

Taking NSAIDs

NSAIDs are usually taken as tablets or capsules but many are also available as a liquid suspension, topical cream or gel or suppository.

Tablets or capsules should be taken with a full glass of liquid, with or shortly after food, and as directed by your doctor. Some NSAIDs are taken only once a day (especially those in a slow-release, sustained-release or retard preparation), while others are taken 2-4 times a day. Your doctor will advise you about the correct dose to take.

It’s important that you go back to your GP if the type and dose of NSAIDs that have been prescribed do not relieve your pain and stiffness after 2 to 4 weeks. A change in the type of NSAID or increased dose could make a big difference to your pain and stiffness.

NSAIDs work quickly, usually within a few hours. However, it can take up to 2 weeks to get the full benefit so do consider taking them regularly to get your symptoms under control.

Side-effects of NSAIDs

Possible side-effects of NSAIDs include:

• stomach upsets
• heartburn
• indigestion
• rashes
• headaches
• wheeziness
• fluid retention

If you develop any new symptoms you should stop taking the drug and tell your doctor as soon as possible.

NSAIDs can damage the lining of the stomach and cause bleeding, especially if you are taking high doses or using them over a long period of time. They should be used with caution and only continue to be used if they are controlling your symptoms.  Drugs known as proton-pump inhibitors (PPIs) are often prescribed along with NSAIDs to help reduce the risk of side-effects on the stomach. Do discuss this with your doctor.

NSAIDs and cardiovascular risk

Research published in The Lancet shows that treatment with NSAIDs at the levels taken by many patients with inflammatory arthritis increases the chance of a heart attack or stroke. Ibuprofen and diclofenac were found to cause about three extra heart attacks for every 1,000 patients treated. Overall, the actual risk of suffering a heart attack from taking long term NSAIDs is raised from 0.8% per year to 1.1% per year

Only naproxen is not associated with increased risk. This is probably because it offsets any excess risk of heart attacks by blocking a related enzyme called COX-1 in blood platelets and thereby reducing the blood’s ability to clot.

Doctors are unlikely to want to prescribe NSAIDs if you have:

• heart disease
• had a heart attack or stroke in the past
• peripheral vascular disease (circulation problems in the limbs, usually in the legs)

You should not take etoricoxib (Arcoxia) if you have high blood pressure which is not under control.

When thinking about cardiovascular risk do bear in mind that NSAIDs hugely benefit many people with axial SpA by reducing pain and inflammation. Without these medications, many would not be able to go about their normal lives, look after children and go to work. You can work to improve your cardiovascular risk by not smoking, following a healthy diet, exercising regularly, keeping your weight down and having your cholesterol and blood pressure checked regularly.

NSAIDs and gastrointestinal risk

NSAIDs are associated with a two to four-fold increased risk of gastrointestinal bleeding. However, the consequences of this type of bleeding are not usually serious.

Rheumatologist, Dr Andrew Keat, explains the first steps in treating axial SpA

If you would like any further information about NSAIDs, or if you have any concerns about your treatment, you should discuss this with your doctor or pharmacist.

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