Monitor NSAID GI Risk in Ankylosing Spondylitis, Study Warns

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In patients with ankylosing spondylitis receiving treatment with non‐steroidal anti‐inflammatory drugs (NSAIDs), timely therapeutic strategies should be implemented in order to manage gastrointestinal risk, say researchers recently writing in the International Journal of Rheumatic Disease.

In ankylosing spondylitis, NSAIDs are recommended as a first‐line treatment option up to a maximum dose in patients with pain and stiffness. However, there are gastrointestinal side effects associated with NSAID use, which may be minor, such ankylosing spondylitis as nausea, dyspepsia, anorexia, and abdominal pain, or life‐threatening, such as gastrointestinal bleeding and perforation. Moreover, patients with ankylosing spondylitis commonly suffer from an inflamed gastrointestinal tract. As ankylosing spondylitis is a chronic disease that requires life‐long treatment after onset, medication adherence often decreases over time, which could compromise the efficacy of NSAIDs.

Along with clinical considerations for effective ankylosing spondylitis management, the assessment of patient‐reported outcomes such as quality of life and functional status should be considered in these patients. Gastrointestinal risk, NSAID adherence and patient‐reported outcomes including disease activity and quality of life have shown significant associations with each other, but their inter‐relationships have been merely studied.

“This study was primarily designed to understand the degree of gastrointestinal risk and patient‐reported outcomes including gastrointestinal‐related symptoms, NSAIDs adherence, disease activity, and quality of life, in ankylosing spondylitis patients,” wrote the authors, led by Tae‐Hwan Kim, M.D., Ph.D., of Hanyang University Hospital for Rheumatic Diseases in Seoul, Korea. “As per this study's results, the prevalence of gastrointestinal risk was noticeable among ankylosing spondylitis patients. The importance of thorough monitoring and management of gastrointestinal risks and symptoms in ankylosing spondylitis patients taking NSAIDs warrants attention.”

THE STUDY

This cross‐sectional, observational study included 596 patients (38.9 ± 12.6 years of age, 82.1 percent male), treated with NSAIDs for at least two weeks in one of six university-based hospitals in Korea. Of the patients, 33.2 percent experienced gastrointestinal symptoms during NSAID treatment and 34.2 percent showed ongoing gastrointestinal symptoms upon enrollment. Demographic and clinical data were collected via a medical chart review and patient survey. Gastrointestinal risk was estimated using Standardized Calculator of Risk for Events (SCORE) and NSAID adherence was assessed with Morisky Medication Adherence Scale‐8 (MMAS‐8). Disease activity and QoL were analyzed with Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and EuroQol‐3L (EQ‐5D, EQ‐visual analog scale [EQ‐VAS]), respectively.

According to SCORE, 37.1% of patients showed moderate to very high gastrointestinal risk. As no patients showed high adherence according to MMAS‐8, 55.3 percent of patients with moderate adherence were considered adherent. Meanwhile, BASDAI and quality of life were 3.5 ± 2.0, 0.6 ± 0.3 (EQ‐5D), and 67.4 ± 19.8 (EQ‐VAS), respectively.

“Higher gastrointestinal risk significantly lowered quality of life,” the authors wrote.

“Although our results on NSAIDs adherence were merely based on patients’ self‐reports, which may have led to over/under‐estimation of adherence level, the study findings imply that motivational education should be sought to improve NSAIDs adherence which may consequently affect long‐term progression of the disease as well as relief of the symptoms,” the authors wrote.

They noted that while the study had several limitations and no direct, causal inference could be made in the relationship of gastrointestinal risk with quality of life, the results “provide practical evidence to suggest timely therapeutic strategies be implemented in order to manage gastrointestinal risk during NSAIDs treatment in ankylosing spondylitis patients.

“Gastrointestinal risk should be monitored and considered as one of the key factors in order to manage quality of life in ankylosing spondylitis patients on NSAID treatment given there was a significant association between gastrointestinal risk and quality of life,” the authors wrote.

REFERENCE

Sang‐Hoon Lee Yong‐wook Park Jung‐Yoon Choe, et al. “Gastrointestinal risk factors and patient‐reported outcomes of ankylosing spondylitis in Korea.” International Journal of Rheumatic Disease. December 29, 2019. https://doi.org/10.1111/1756-185X.13758