Are NSAIDs disease-modifying antirheumatic drugs (DMARDS)?

Non-steroidal anti-inflammatory drugs (NSAIDs), including Coxibs, are recommended as first-line drug treatment for patients with ankylosing spondylitis (AS) with inflammatory back pain and stiffness. Continuous treatment with NSAIDs is preferred for patients with persistently active, symptomatic disease.1

Although many young patients with AS may be at lower risk of gastrointestinal and cardiac adverse events with NSAID therapy than older patients with other rheumatic diseases, patients and physicians alike continue to raise questions about the optimal role of these agents in AS.

An earlier study examined phenylbutazone in AS and concluded that this agent not only improved the symptoms of spinal pain and stiffness, but also appeared to influence progression of new bone formation in the spine.2 A study by Wanders et al in 2005 found that the continuous use of celecoxib, in contrast with on-demand use, was also associated with less radiographic progression in AS.3 The latter was measured determining the change in the modified Stokes Ankylosing Spondylitis Spinal Score (mSASSS) over a 2-year interval. This provocative finding heightened interest in the potential disease-modifying effects of NSAIDs. However, the study of Wanders et al entailed relatively small differences in total celecoxib dose between groups. The study has awaited confirmation in other AS cohorts. We recently reported a reduced rate of progression of mSASSSs in patients who continue to take NSAIDs while being on anti-tumour necrosis factor (TNF) agents for AS.4

Two papers now published in the Annals of Rheumatic Disease provide supportive evidence that NSAIDs may slow the progression of bony change of the spine in AS.5 ,6 Data from the German Early Spondyloarthritis Inception Cohort (GESPIC) suggests that patients with AS with a high NSAID intake over 2 years demonstrated slowing of new bone formation in the spine compared with patients with low NSAID …