“If confirmed,” she says by email, “it is possible that subsequent treatment guidelines would recommend for or against a specific NSAID as first-line treatment in spondyloarthritis.”
Daniel Solomon, MD, MPH, chief, Section of Clinical Sciences, Divisions of Rheumatology and Pharmacoepidemiology at Brigham and Women’s Hospital in Boston comments to Reuters Health by email, “We know that all NSAIDs confer cardiovascular [CV] risk. However, most patients with normal CV risk who use these agents intermittently will not experience harm. Chronic use of NSAIDs in patients with certain risk factors is associated with substantial potential for CV and other adverse events.”
“The best data we have on these issues comes from large randomized controlled trials, such as PRECISION which tested different NSAIDs across patients with osteoarthritis (OA) or rheumatoid arthritis (RA),” says Dr. Solomon, who was a coauthor on PRECISION.2
“No important differences were found in relative risks across different NSAIDs by disease,” he notes. “In other words, patients with OA and RA experienced the same relative risks by NSAID. However, the CV risk was higher in RA so absolute risks were higher for the RA patients.”
The authors of the current study “specifically examined patients with spondyloarthritis and with OA and found that use of current diclofenac conferred an increased relative risk for CV events compared to past use among both patient groups, but the relative risk was increased for SpA compared with OA,” he says.
“This is interesting and there are biologic reasons why this is plausible,” he says, “but by no means are these results practice-changing. NSAID observational studies are very tricky because of confounding by indication as well as over the counter NSAID use. These results should generate new hypotheses that might be tested in prospective cohorts.”
Patients should not be told to steer clear of diclofenac, he adds. “All NSAIDs, including celecoxib, confer CV, gastrointestinal and renal risk. Patients should not use these agents chronically if they have known CV or renal disease.”
Reference
- Dubreuil M, Louie-Gao Q, Peloquin CE, et al. Risk of myocardial infarction with use of selected non-steroidal anti-inflammatory drugs in patients with spondyloarthritis and osteoarthritis. Ann Rheum Dis. 2018 Apr 19. pii: annrheumdis-2018-213089. [Epub ahead of print]
- Nissen SE, Yeomans ND, Solomon DH, et al. Cardiovascular safety of celecoxib, naproxen or ibuprofen for arthritis. N Engl J Med. 2016 Dec 29;375(26):2519-29. Epub 2016 Nov 13.
