Treatment of Spondyloarthropathy: Difference between revisions

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Due to the chronic nature of these conditions, patients may need to take NSAIDs continuously or for long periods of time. This can cause various side effects:<ref name=":1" />
Due to the chronic nature of these conditions, patients may need to take NSAIDs continuously or for long periods of time. This can cause various side effects:<ref name=":1" />
* Gastrointestinal Effects
** Gastrointestinal complications may be relatively minor (i.e. dyspepsia, nausea, and heartburn) or severe (life-threatening gastrointestinal bleed). The risk of adverse effects increases with age and for patients also taking other medications (such as aspirin and corticosteroids).<ref name=":1" />
* Renal Adverse Effects
** Around one to five percent of patients who require NSAIDs regularly go on to develop adverse renal effects, including:<ref name=":1" />
*** Reduction in glomerular filtration rate
*** Acute renal failure
*** Renal papillary necrosis
*** Nephrotic syndrome
*** Acute interstitial nephritis
*** Chronic renal failure
*** Fluid and electrolyte retention
* Cardiovascular adverse effects
** NSAIDs can worsen hypertension and have been linked to a heightened risk for myocardial infarction.<ref name=":1" />


===== Gastrointestinal Effects =====
== Disease Modifying Anti-Rheumatic Drugs ==
Gastrointestinal complications may be relatively minor (i.e. dyspepsia, nausea, and heartburn) or severe (life-threatening gastrointestinal bleed). The risk of adverse effects increases with age and for patients also taking other medications (such as aspirin and corticosteroids).<ref name=":1" />
Disease modifying anti-rheumatic drugs (DMARD) are immunosuppressive and immunomodulatory agents. They are classified as either convention DMARDs or biological DMARDs.<ref>Benjamin O, Bansal P, Goyal A, et al. Disease Modifying Anti-Rheumatic Drugs (DMARD) [Updated 2020 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK507863/</nowiki></ref>


===== Renal Adverse Effects =====
Conventional DMARDs have been considered an alternative, second-line treatment for patients who do not tolerate or respond to NSAIDs.<ref name=":3">Simone D, Nowik M, Gremese E, Ferraccioli GF. Disease-modifying Antirheumatic Drugs (DMARD) and Combination Therapy of Conventional DMARD in Patients with Spondyloarthritis and Psoriatic Arthritis with Axial Involvement. J Rheumatol Suppl. 2015; 93: 65-9. </ref>  DMARDs can either be used on their own (monotherapy) or in combination with other medications.<ref name=":0" /> However, there is not enough evidence to support their efficacy.<ref name=":3" /> It is believed that they can be effective in managing peripheral spondyloarthropathy, but they are not considered effective medications for axial symptoms.<ref name=":1" /><ref name=":3" /><ref>Lee, R.Z., Veale, D.J. Management of Spondyloarthropathy. Drugs. 2002; 62: 2349–59.</ref> They are, however, considered effective and used widely to manage psoriatic arthritis.<ref name=":3" />
Around one to five percent of patients who require NSAIDs regularly go on to develop adverse renal effects. <ref name=":1" />These include:<ref name=":1" />
* Reduction in glomerular filtration rate
* Acute renal failure
* Renal papillary necrosis
* Nephrotic syndrome
* Acute interstitial nephritis
* Chronic renal failure
* Fluid and electrolyte retention


===== Cardiovascular adverse effects =====
Examples of DMARDs are:<ref name=":0" /><ref name=":3" />
NSAIDs can worsen hypertension and have been linked to a heightened risk for myocardial infarction.<ref name=":1" />
* Sulphasalazine - this DMARD has often been used to treat patients with ankylosing spondylitis, but few studies have explored its efficacy. One study found some improvement in peripheral joint disease, but no improvement in axial symptoms. Another study found that it was no better than a placebo in managing overall inflammatory low back pain<ref name=":3" />
* Methotrexate - the evidence for this DMARD is even more limited in spondyloarthropathy although it is used extensively in rheumatoid arthritis and is considered to be the first-choice DMARD for psoriatic arthritis<ref name=":3" />
* Leflunomide - while there is a lack of strong evidence, leflunomide is often used to treat psoriatic arthritis in clinical practice<ref name=":3" />


== References ==
[[Category:Course Pages]]
[[Category:Course Pages]]
[[Category:Rheumatology]]
[[Category:Rheumatology]]
<references />

Revision as of 02:30, 27 November 2020

Spondyloarthropathy is an umbrella term for a group of seronegative inflammatory conditions. Included in this family of diseases are:

A primary aim of treatment is to reduce inflammation. In addition, issues such as pain, stiffness, fatigue, sleep disturbance, depression, reduced physical activity levels, and increased cardiovascular disease risk need to be addressed.[1]

Many different health care professionals are involved in the management of spondyloarthropathy, from diagnosis to treatment. This page will explore both the pharmacological and nonpharmacological treatment options for spondyloarthropathy.

Pharmacological Treatment[edit | edit source]

Non-Steroidal Anti-Inflammatory Drugs[edit | edit source]

Initial treatment of spondyloarthropathy is focused on non-steroidal anti-inflammatory drugs (NSAIDs) and exercise management.[1]

NSAIDs are commonly used to manage pain and inflammation, and as an antipyretic (i.e. to treat fever / reduce temperature).[1] NSAIDs work by blocking the enzyme cyclooxygenase (COX). There are two COX isoforms: COX-1 and COX-2. COX-1 has a homeostatic role while COX-2 generates the prostaglandins seen in fever, inflammation, and carcinogenesis.[2]

NSAIDs are available in tablets, capsules, suppositories, creams, gels and potentially as injections. Some NSAIDs can be bought over-the-counter while others require a prescription.[1] Commonly used NSAIDs are:[1]

  • Diclofenac
  • Ibuprofen
  • Neproxin
  • Arcoxia
  • Etoricoxib

For many years, NSAIDs have been used as the first-line treatment for spondyloarthropathy.[2][3] Around 70 to 80 percent of patients with axial spondyloarthritis take NSAIDs with varying degrees of efficacy.[4] A positive response to NSAIDs has been included as a criterion for the diagnosis of inflammatory back pain and spondyloarthropathy in the ASAS criteria.[4][5]

Patients can respond quite differently to NSAIDs, so it may be necessary to try different forms of NSAIDs to determine the best option. A poor response to NSAIDs is considered to be a poor prognostic sign in axial spondyloarthritis.[4]

Due to the chronic nature of these conditions, patients may need to take NSAIDs continuously or for long periods of time. This can cause various side effects:[2]

  • Gastrointestinal Effects
    • Gastrointestinal complications may be relatively minor (i.e. dyspepsia, nausea, and heartburn) or severe (life-threatening gastrointestinal bleed). The risk of adverse effects increases with age and for patients also taking other medications (such as aspirin and corticosteroids).[2]
  • Renal Adverse Effects
    • Around one to five percent of patients who require NSAIDs regularly go on to develop adverse renal effects, including:[2]
      • Reduction in glomerular filtration rate
      • Acute renal failure
      • Renal papillary necrosis
      • Nephrotic syndrome
      • Acute interstitial nephritis
      • Chronic renal failure
      • Fluid and electrolyte retention
  • Cardiovascular adverse effects
    • NSAIDs can worsen hypertension and have been linked to a heightened risk for myocardial infarction.[2]

Disease Modifying Anti-Rheumatic Drugs[edit | edit source]

Disease modifying anti-rheumatic drugs (DMARD) are immunosuppressive and immunomodulatory agents. They are classified as either convention DMARDs or biological DMARDs.[6]

Conventional DMARDs have been considered an alternative, second-line treatment for patients who do not tolerate or respond to NSAIDs.[7]  DMARDs can either be used on their own (monotherapy) or in combination with other medications.[1] However, there is not enough evidence to support their efficacy.[7] It is believed that they can be effective in managing peripheral spondyloarthropathy, but they are not considered effective medications for axial symptoms.[2][7][8] They are, however, considered effective and used widely to manage psoriatic arthritis.[7]

Examples of DMARDs are:[1][7]

  • Sulphasalazine - this DMARD has often been used to treat patients with ankylosing spondylitis, but few studies have explored its efficacy. One study found some improvement in peripheral joint disease, but no improvement in axial symptoms. Another study found that it was no better than a placebo in managing overall inflammatory low back pain[7]
  • Methotrexate - the evidence for this DMARD is even more limited in spondyloarthropathy although it is used extensively in rheumatoid arthritis and is considered to be the first-choice DMARD for psoriatic arthritis[7]
  • Leflunomide - while there is a lack of strong evidence, leflunomide is often used to treat psoriatic arthritis in clinical practice[7]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Martey C. Treatment in Spondyloarthropathy Course. Physioplus 2020.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Wong RSY. Disease-Modifying Effects of Long-Term and Continuous Use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) in Spondyloarthritis. Adv Pharmacol Sci. 2019; 2019: 5324170.
  3. ↑ Toussirot E. Pharmacological management of axial spondyloarthritis in adults. Expert Opin Pharmacother. 2019; 20(12): 1483-91.
  4. ↑ 4.0 4.1 4.2 Braun J, Sieper J. Therapy of ankylosing spondylitis and other spondyloarthritides: established medical treatment, anti-TNF-alpha therapy and other novel approaches. Arthritis Res. 2002; 4(5): 307-21.
  5. ↑ Slobodin G, Eshed I. Non-Radiographic Axial Spondyloarthritis. Isr Med Assoc J. 2015; 17(12): 770-6.
  6. ↑ Benjamin O, Bansal P, Goyal A, et al. Disease Modifying Anti-Rheumatic Drugs (DMARD) [Updated 2020 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507863/
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 Simone D, Nowik M, Gremese E, Ferraccioli GF. Disease-modifying Antirheumatic Drugs (DMARD) and Combination Therapy of Conventional DMARD in Patients with Spondyloarthritis and Psoriatic Arthritis with Axial Involvement. J Rheumatol Suppl. 2015; 93: 65-9.
  8. ↑ Lee, R.Z., Veale, D.J. Management of Spondyloarthropathy. Drugs. 2002; 62: 2349–59.
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