NSAIDs in rheumatoid arthritis (RA)

NSAIDs are used to control the synovitis.

• NSAID use in RA(1):
  • all NSAIDs and selective COX-2 inhibitors can adversely affect renal function, promote fluid retention and exacerbate hypertension
  • newer selective COX-2 inhibitors have been associated with an excess of cardiovascular events which has led to the withdrawal of rofecoxib and significant changes to the labelling and use of celecoxib and etoricoxib
  • the use of non-selective (ns) NSAIDs/selective COX-2 inhibitors should be considered carefully in patients with RA
    • continued requirement for nsNSAID/selective COX-2 inhibitor therapy in some patients may indicate that further adjustment to their disease-modifying anti-rheumatic drug (DMARD) therapy is indicated to control inflammation better
  • the NSAID/selective COX-2 inhibitor dose should be reviewed and the lowest effective dose should be used for the shortest period of time

Notes (1):

• some patients with RA will additionally be on treatment with low-dose aspirin (either because of established cardiovascular disease or a primary prevention measure) as well as an NSAID
  • co-prescription of ibuprofen and low-dose aspirin should be avoided
  • the majority of patients on aspirin plus a NSAID will also require some form of gastroprotection
• NICE state that (2):
  • analgesics should be offered (for example, paracetamol, codeine or compound analgesics) to people with RA whose pain control is not adequate, to potentially reduce their need for long-term treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or cyclo-oxygenase-2 (COX-2) inhibitors
  • oral NSAIDs/COX-2 inhibitors should be used at the lowest effective dose for the shortest possible period of time
  • when offering treatment with an oral NSAID/COX-2 inhibitor
    • first choice should be either a standard NSAID or a COX-2 inhibitor (other than etoricoxib 60 mg)
      • in either case, these should be co prescribed with a proton pump inhibitor (PPI)
  • all oral NSAIDs/COX-2 inhibitors have analgesic effects of a similar magnitude but vary in their potential gastrointestinal, liver and cardio-renal toxicity; therefore, when choosing the agent and dose, healthcare professionals should take into account individual patient risk factors, including age
  • if a person with RA needs to take low-dose aspirin, healthcare professionals should consider other analgesics before substituting or adding an NSAID or COX-2 inhibitor (with a PPI) if pain relief is ineffective or insufficient
  • if NSAIDs or COX-2 inhibitors are not providing satisfactory symptom control, review the disease-modifying or biological drug regimen

Reference:

1. ARC. Management of cardiovascular disease in RA and SLE. Hands On 2006;8:1-4.
2. NICE (February 2009). Rheumatoid arthritis- The management of rheumatoid arthritis in adults