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Combination of NSAIDs and TNF inhibitors may benefit ankylosing spondylitis patients

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New research suggests that a combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and TNF inhibitors (TNFi) may help slow down spine damage in ankylosing spondylitis (AS).

Around 200,000 people in the UK live with AS, a painful and progressive form of arthritis which causes inflammation in the spine and other joints.

Researchers at the University of California, San Francisco, together with other investigators, analysed the direct and interactive effects of a combination of the two therapies on X-ray progression of AS.

“Until 2003, the only drugs available to treat AS were NSAIDs. When the first TNFi was approved in 2003, the disease state changed. Suddenly, we could offer therapies to patients with incredible efficacy,” said Dr Lianne S. Gensler, director of the Ankylosing Spondylitis Clinic at the University of California, San Francisco, and lead author of the study.

However, despite the robust clinical response, TNFi could not show the disease progression (by X-ray) slowing down, Dr Gensler noted.

“Researchers posited that there was a different mechanism to explain the damage that occurred in AS, and that though we were treating the inflammation, we may not be addressing the ankylosis that appeared to continue. At the same time, several studies came out looking at NSAIDs to see if they could slow down progression, and these results were mixed,” she said. “Despite the controversy, as we saw patients on these drugs over the next decade, the clinical experience did not match the ‘evidence´ that suggested no effect.

“Patients were not developing the severe damage we had become accustomed to. Based on the controversial data, and having prospectively collected detailed medication data in a longitudinal cohort [PSOAS — Prospective Study of Outcomes in AS] over 10 years, we were able to ask the research question in a longitudinal manner, not only addressing the effects of TNFi, but also NSAIDs and the relationship between these two medications.”

The findings of the study were presented at the recent American College of Rheumatology annual meeting in Washington.

Multivariate results showed that there was significant interaction between TNFi and NSAIDs, the American College of Rheumatology said. When TNFi were used with higher doses of NSAIDs (at least 50% of the maximum daily dose), patients had a 70% reduction in radiographic progression.

“This is the first study to show this relationship and potentially sheds light on why prior study results have been so controversial,” Dr Gensler commented. “I think it is important to remember that despite the results, not every patient will progress or warrant this kind of regimen. That said, for those with greater risk, this combination may be especially helpful.”