NSAIDs for axial spondyloarthritis

Kroon, 2015Sieper, 2016Wanders, 2005

In combination with exercise, nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line therapy for the management of pain and inflammation in axial spondyloarthritis.

While the symptomatic benefit of NSAIDs is well established, there is conflicting evidence regarding the role of regular NSAID use in slowing spinal ankylosis. In general, NSAIDs are only used for symptom control in axial spondyloarthritis.

All of the NSAIDs listed below are equally effective and drug choice should be based on patient factors (eg comorbidities); see Choosing an NSAID for advice on drug choice. For symptom control in axial spondyloarthritis, use:

1celecoxib 100 to 200 mg orally, daily in 1 or 2 divided doses, until symptoms subside celecoxib celecoxib celecoxib

OR

1etoricoxib 30 to 60 mg orally, daily until symptoms subside etoricoxib etoricoxib etoricoxib

OR

1ibuprofen immediate-release 200 to 400 mg orally, 3 or 4 times daily until symptoms subside ibuprofen ibuprofen ibuprofen

OR

1indometacin 25 to 50 mg orally, 2 to 4 times daily until symptoms subside indometacin indometacin indometacin

OR

1ketoprofen modified-release 200 mg orally, daily until symptoms subside ketoprofen ketoprofen ketoprofen

OR

1meloxicam 7.5 to 15 mg orally, daily until symptoms subside meloxicam meloxicam meloxicam

OR

1naproxen immediate-release 250 to 500 mg orally, twice daily until symptoms subside naproxen naproxen naproxen

OR

1naproxen modified-release 750 to 1000 mg orally, daily until symptoms subside naproxen naproxen naproxen

OR

1piroxicam 10 to 20 mg orally, daily until symptoms subside piroxicam piroxicam piroxicam

OR

2diclofenac 25 to 50 mg orally, 2 or 3 times daily until symptoms subside. diclofenac diclofenac diclofenac

People with axial spondyloarthritis often benefit from taking NSAIDs in the evening to minimise night pain and morning stiffness. It is not unusual to use the upper end of the recommended dosage range.

People who suffer from pain throughout the night and stiffness in the morning may find a rectal NSAID improves their sleep quality. If a rectal NSAID is preferred, use:

1indometacin 100 mg rectally, once or twice daily indometacin indometacin indometacin

OR

2diclofenac 25 to 50 mg rectally, 2 or 3 times daily. diclofenac diclofenac diclofenac

The risk of harms from NSAID use in people with axial spondyloarthritis is generally relatively low because the disease typically affects younger adults; some data show that NSAID-related harms may not differ from placebo in the short term. Furthermore, the risk of harms is generally outweighed by the benefits of use because of the proven efficacy of NSAIDs in the treatment of axial spondyloarthritis. NSAIDs are preferred over other analgesics because of their favourable benefit–harm profile in this setting.

Note: The risk of harms of NSAIDs is generally outweighed by the benefits of use because of the proven efficacy of NSAIDs in the treatment of axial spondyloarthritis.

Opioids should not be used as they are unlikely to be beneficial for axial spondyloarthritis pain and are associated with a considerable risk of harm—see Drugs that have a limited role for musculoskeletal pain for more information.