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Phenylbutazone was discovered in 1946 and promptly exhibited efficacy in various rheumatic diseases in the early 1950s. Its efficacy on pain and general well-being was especially present in ankylosing spondylitis (AS), which was then known as ‘rheumatoid spondylitis’.1 ,2 However, even in the early days, non-steroidal anti-inflammatory drugs (NSAIDs) were not considered harmless drugs, as the toxic properties on bone marrow or the gastrointestinal tract, and the appearance of oedema or skin rash, although commonly reversible, were already apparent from the start. Up until now, a various range of NSAIDs have taken centre stage and have been the cornerstone of treatment of patients with spondyloarthritis (SpA).3 ,4 Despite the common use of these drugs for almost seven decades, there are still a number of unanswered questions, such as which type of NSAIDs we should preferentially use in axial SpA (AxSpA) and whether these agents should be given continuously or on demand.
All NSAIDs are effective anti-inflammatory drugs because of their ability to inhibit the biosynthesis of prostaglandins at the level of the cyclo-oxygenase (COX) enzyme; however, this mode of action also explains a number of side effects. While selective COX-2 inhibitors have claimed to induce fewer side effects through the omission of COX-1 inhibition, large meta-analyses have failed to demonstrate this superiority of COX selectivity in vascular and complicated gastrointestinal outcomes compared with conventional NSAIDs.5 ,6 Furthermore, head-to-head comparisons of efficacy in AxSpA regarding the available NSAIDs are scarce. In AS, the treatment effect of piroxicam 20 mg, meloxicam 15 mg and meloxicam 22.5 mg did not differ significantly after 1 year of treatment regarding the patient’s overall assessment,7 and Sieper et al8 reported that the efficacy of diclofenac compared with celecoxib was non-inferior regarding symptom relief. In contrast, other studies have demonstrated superior efficacy of …