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Continuous NSAID use for AS linked to increased hypertension risk
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Continuous use of NSAIDs for the treatment of ankylosing spondylitis is associated with a 12% increased risk for incident hypertension, compared to noncontinuous or no NSAID use, according to data published in Arthritis Care & Research.
“Hypertension is common in individuals with AS, and the prevalence of this comorbidity in AS studies is about 30%,” Jean W. Liew, MD, of the University of Washington, in Seattle, told Healio Rheumatology. “Of course, the age and gender distribution in these studies matters, and it has been previously shown that hypertension is more common among those with AS, when compared to the general population, after those factors are accounted for.”
“We also have evidence connecting the use of NSAIDs with increased blood pressure, and increased cardiovascular events, though this likely depends on COX-2 selectivity,” she added. “NSAIDs are the first-line pharmacologic therapy in AS.”
To analyze the link between NSAID use and incident hypertension, Liew and colleagues studied longitudinal data from the Prospective Study of Outcomes in AS (PSOAS) cohort, which included adults recruited from investigators’ clinics, patient support groups and community rheumatologists. The five participating study sites were located in Los Angeles; Houston; San Francisco; Bethesda, Maryland; and Brisbane, Australia. The researchers included 628 patients with AS from the PSOAS cohort in their final analysis. All included patients had at least 1 year of follow-up and no hypertension at baseline.
Participants in the cohort were examined every 4 to 6 months using questionnaires assessing disease activity and functional impairment. The researchers defined hypertension based on patient-reported outcomes, the use of anti‐hypertensive medication, a systolic blood pressure of 140 mm Hg or greater, or a diastolic blood pressure of 90 mm Hg or greater, reported on two consecutive follow-up visits. Liew and colleagues dichotomized continuous NSAID use based on the validated NSAID index. In addition, they used Cox proportional hazards models to determine the association of NSAID use as a time-varying exposure with hypertension.
According to the researchers, 200 of the 628 included patients used NSAIDS continuously. During a median of 7 years of follow-up, a total of 129 patients developed incident hypertension. Among these patients with new hypertension diagnoses during follow-up, 40% were receiving continuous NSAIDS, 47% were using TNF inhibitors and 16% were on both NSAIDs and TNF inhibitors at baseline. After controlling for other variables, the researchers determined that continuous NSAID use was associated with an HR of 1.12 for hypertension (95% CI, 1.04-1.2), compared with noncontinuous or no use. This link remained unchanged in specific subgroups based on age, BMI, biologic use or disease activity.
“In clinical practice, I would recommend focusing on discussing the risks of NSAID therapy with patients and being vigilant about screening for cardiovascular risk factors, including hypertension, and making sure that these conditions are treated in conjunction with primary care,” Liew said. “I would also suggest some caution in interpreting the findings of this study.”
“This is a study of association, and the risk was modest, so I would caution clinicians against using these results to recommend stopping NSAID treatment as a general measure,” she added. “We also didn’t look at whether this increased risk of hypertension translates to an increased risk of cardiovascular events. However, there are other studies that have suggested that NSAID use might actually be protective against [myocardial infarction] or stroke in individuals with AS.” – by Jason Laday
Disclosure: Liew reports no relevant financial disclosures. Please see the full study for additional authors’ disclosures.
Perspective
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David A. McLain, MD, FACP, FACR
The ACR recently published guidelines for the treatment of ankylosing spondylitis and spondyloarthritis (AS/SpA), and the first tier of treatment recommended was NSAIDs. However, the ACR did recommend non-continuous use of NSAIDs — where possible.
From many population studies, it is known that AS patients have an increased risk of cardiovascular (CV) disease. Certain NSAIDs have also been shown to increase CV risk. In this prospective cohort study, the researchers investigated the occurrence of incident hypertension following the introduction of NSAIDs. They found that the odds ratio was 1.12 for incident hypertension with NSAIDs — in other words, that there was 12% more incident hypertension in the NSAID group after controlling for confounders.
However, the incidence of hypertension with TNF inhibitors was actually higher by percentage (47% vs. 40% for NSAIDs) and significant in certain analyses, but the overall P value was 0.09. Prospective studies that are this large and that isolate one variable are difficult to perform, and the researchers are to be commended for their efforts in this area.
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