CHARACTERISTICS OF ADMINISTRATION OF NONSTEROIDAL ANTI-INFLAMMATORY DRUGS IN ANKYLOSING SPONDYLITIS: CLINICAL OBSERVATION

The study objective is to demonstrate characteristics of prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) for ankylosing spondylitis (AS) through a clinical case.

Materials and methods. Male patient N., 34 years old, sought medical help complaining of pain in the cervical, thoracic, and lumbar spine, predominantly at night, at rest; limited range of motion in cervical and lumbar spine, pain in the area of external thigh surface, morning tightness longer than 2 hours. Stomachache after eating was also a complaint. The first episode of inflammatory pain was 10 years ago. Diagnosis of AS was determined 2 years ago, NSAIDs were prescribed which the patient didn’t take regularly. Based on clinical and laboratory examination, the following diagnosis was made. Main disorder: ankylosing spondylitis, late stage, stage III bilateral sacroiliitis, frontal spondylitis, high activity (BASDAI 5, 7, ASDAS-CRP 2, 7), HLA-В27-associated, with extra-articular manifestations (stage II bilateral coxitis, tendinitis of the shoulder rotator cuff muscle – superspinatus, supraspinatus, teres minor muscle, trochanteritis on both sides). Secondary diagnosis: NSAID-gastropathy, gastroesophageal reflux disease with esophagitis, gastroduodenitis associated with H. pylori. Meloxicam 15 mg/day in constant continuous regimen, methotrexate 12.5 mg SC once a week, folic acid 1 mg 5 days a week, sirdalud 4 mg 2 times a day, H. Pylori eradication therapy, glucocorticoid administration in the area of inflamed entheses were prescribed.

Results. During the patient’s visit a month later, significant positive dynamics were observed: decreased pain in the lumbar, cervical, and thoracic spine, decreased pain in the shoulder joints, pain relief in the area of the greater trochanters, full active and passive range of motion in the shoulder joints. Duration of morning tightness was 1.5 hours. No complaints of pain in the epigastric region. In blood test: clinical and biochemical characteristics without abnormalities, С-reactive protein decreased from 62.5 to 20 mg/l. BASDAI 4, 3, ASDAS-CRP 2.0. Treatment with NSAIDs, methotrexate, proton pump inhibitor, folic acid was continued.

Conclusion. NSAIDs are leading drugs for treatment of AS. Their prescription allows to relieve spinal pain and tightness, decreases enthesitis manifestations, exudative changes in the joints, allows to prevent or slow down structural changes in the spine. A very important treatment aspect is providing patients with information on the necessity of long-term continuous administration of NSAIDs and basic drugs, as well as on possible adverse events, regular laboratory control, necessity of gastroprotective drugs. Effectiveness of meloxicam in AS therapy was proved in a number of multicenter studies with a large number of patients. Meloxicam’s effectiveness is comparable to traditional NSAIDs – the “golden standard” (diclofenac, piroxicam, naproxem), but it’s more safe.

1. Rheumatology secrets. Ed. S.G. West; translation from English, ed. O.M. Lesnyak. Moscow: GEOTARMedia, 2018. 760 p. (In Russ.).

2. Bochkova A.G. Guidelines on care for patients with ankylosing spondylitis. Based on the materials of the Assessment in Ankylosing Spondylitis International Working Group (ASAS). Sovremennaya revmatalogiya = Modern Rheumatology Journal 2009;3(4):5–10. (In Russ.).

3. Volnukhin E.V., Galushko E.A., Bochkova A.G. et al. Clinical diversity of ankylosing spondylitis in the real practice of a rheumatologist in Russia. Part 1. Nauchno-prakticheskaya revmatologiya = Rheumatology Science and Practice 2012;50(2):44–9. (In Russ.).

4. Boonen A., Cruyssen B.V., de Vlam K. et al. Spinal radiographic changes in ankylosing spondylitis: association with clinical characteristics and functional outcome. J Rheumatol 2009;36(6): 1249–55.

5. Miedany Y.E. Treat to target in spondyloarthritis: the time has come. Curr Rheumatol Rev 2015;10(2):87–93.

6. Rohekar S., Chan J., Tse S.M. et al. 2014 Update of the Canadian Rheumatology Association/Spondyloarthritis research consortium of Canada treatment recommendations for the management of spondyloarthritis. Part I: principles of the management of spondyloarthritis in Canada. J Rheumatol 2015;42(4):654–64.

7. Callhoff J., Sieper J., Weiβ A. et al. Efficacy of TNFα blockers in patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis: a meta-analysis. Ann Rheum Dis 2015;74(6):1241–8.

8. Ward M.M. Update on the American College of Rheumatology/Spondyloarthritis Research and Treatment Network/Spondylitis Association of America axial spondyloarhtritis treatment guidelines project. Clin Rheumatol 2014;33(6):739–40.

9. Gaidukova I.Z., Rebrov A.P., Otteva E.N. et al. Use of nonsteroidal anti-inflammatory drugs for the treatment of axial spondyloarthritis, including ankylosing spondylitis, monitoring their efficacy and safety (draft guidelines of the Expert Spondyloarthritis Diagnosis and Treatment Group). Nauchno-prakticheskaya revmatologiya = Rheumatology Science and Practice 2016;54(1S):67–74. (In Russ.).

10. Yan Y., Guo TM. Zhu C. Effects of NonSteroidal Anti-Inflammatory Drugs on Serum Proinflammatory Cytokines in the Treatment of Ankylosing Spondylitis. Biochem Cell Biol 2018 Jan 11. DOI: 10.1139/bcb-2017-0267.

11. Wanders A., van der Heijde D., Landewe R. et al. Nonsteroidal anti-inflammatory drugs reduce radiographic progression in patients with ankylosing spondylitis: a randomized clinical trial. Arthritis Rheum 2005;52(6):1756–65.

12. Varkas G., Jans L., Cypers H. et al. Brief Report: Six-Week Treatment of Axial Spondyloarthritis Patients With an Optimal Dose of Nonsteroidal Antiinflammatory Drugs: Early Response to Treatment in Signal Intensity on Magnetic Resonance Imaging of the Sacroiliac Joints. Arthritis Rheumatol 2016;68(3):672–8.

13. Sampaio-Barros P.D., Costallat L.T., Bertolo M.B. et al. Methotrexate in the treatment of ankylosing spondylitis. Scand J Rheumatol 2000;29(3):160–2.

14. Lian F., Zhou J., Wei C. et al. Anti-TNFα agents and methotrexate in spondyloarthritis related uveitis in a Chinese population. Clin Rheumatol 2015;34(11): 1913–20.

15. Carbo M.J.G., Spoorenberg A., Maas F. et al. Ankylosing spondylitis disease activity score is related to NSAID use, especially in patients treated with TNFα inhibitors. PLoS One 2018;13(4):e0196281.

16. Kiltz U., Sieper J., Braun J. ASAS recommendations on the use of TNF inhibitors for patients with axial spondyloarthritis: evaluation of the 2010 update in the German-speaking area. J Rheumatol 2013;72(1):81–8.

17. Wang R., Dasgupta A., Ward M.M. Comparative efficacy of non-steroidal anti-inflammatory drugs in ankylosing spondylitis: a Bayesian network meta-analysis of clinical trials. Ann Rheum Dis 2016;75(6):1152–60.

18. Ward M.M., Deodhar A., Akl E.A. et al. American College of Rheumatology/ Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol 2016;68:282–98.

19. Braun J., Kiltz U., Sarholz M. et al. Monitoring ankylosing spondylitis: clinically useful markers and prediction of clinical outcomes. Expert Rev Clin Immunol 2015;11(8):935–46.

20. Singh G., Lanes S., Triadafilopoulos G. Risk of serious upper gastrointestinal and cardiovascular tromboembolic complications with meloxicam. Am J Med 2004;117(2):100–6.

21. Chan F.K., Lanas A., Scheiman J.et al. Celecoxib versus omeprazole and diclofenac in patients with osteoarthritis and rheumatoid arthritis (CONDOR): a randomised trial. Lancet 2010;376(9736):173–9.

22. Karateev A.E., Nasonov E.L., Yakhno N.N. et al. Clinical guidelines «Rational use of nonsteroidal anti-inflammatory drugs (NSAIDs) in clinical practice». Sovremennaya revmatalogiya = Modern Rheumatology Journal 2015;9(1):4–23. (In Russ.).

23. Derry S., Moore R.A., Rabbie R. Topical NSAIDs for chronic muscoloskeletal pain in adults. Cochrane Database Syst Rev 2012;9:CD007400.

24. Tielleman T., Bujanda D., Cryer B. Epidemiology and risk factors for upper gastrointestinal bleeding. Gastrointest Endosc Clin N Am 2015;25(3):415–28.

25. Niwa Y., Nakamura M., Ohmiya N. et al. Efficacy of rebamipide for diclofenac induced small-intestinal mucosal injuries in healthy subjects: a prospective, randomized, double-blinded, placebo-controlled, crossover study. J Gastroenterol 2008;43(4):270–6.

26. Moroz E.V., Karateev A.E. Rebamipide: effective drug prevention of NSAID enteropathy is possible. Sovremennaya revmatalogiya = Modern Rheumatology Journal 2016;10(4): 97–105. (In Russ.).

27. Nasonov E.L. Cardiovascular effects of nonsteroidal anti-inflammatory drugs. Nauchno-prakticheskaya revmatologiya = Rheumatology Science and Practice 2003;41(3):28–32. (In Russ.).

28. Xie R.L., Li X.H., Kang X.T. Methotrexate in conjunction with meloxicam for treating ankylosing spondylitis: a clinical observation of the efficacy and safety. Di Yi Jun Yi Da Xue Xue Bao 2003;23(5):460–2.

29. Karateev A.E., Erdes Sh.F. Use of nonsteroidal antiinflammatory drugs in ankylosing spondylitis: long and hard! Terapevticheskij arhiv = Therapeutic Archive 2014;86(11):123–7. (In Russ.).

30. Wendling D., Lukas C., Paccou J. et al. Recommendations of the French Society for Rheumatology (SFR) on the every day management of patients with spondyloarthritis. Joint Bone Spine 2014;81(1):6–14.