Background/Purpose: The inhibitory effect of TNF inhibitor (TNFi) treatment on spinal radiographic progression in patients with radiographic Axial Spondyloarthritis (r-axSpA), remains controversial. However, current evidence suggests that TNFi treatment seems to stabilize the structural damage of hip arthritis in these patients1. The aim of this studyis to investigate whether the addition of an NSAIDS to TNFi therapy in patients with r-­axSpA, might have a better inhibitory effect on radiographic progression in the spine and hip, compared to TNFi therapy alone.

Methods: 262 patients with r-­axSpA [189 men; age: 44±12years, disease duration: 7.3 years (IQR:2;15)] were included. Radiographs of spine and pelvis, obtained at baseline (i.e., before TNFi initiation), compared retrospectively to those obtained after 2.5±0.7 and 7±2.3 years of TNFi combined, or not with NSAIDs. Spinal X-rays were scored by mSASSS. Both hips were scored by BASRI-hip score and mean joint space width (MJSW)1. The spinal radiographic progression was assessed as the formation of new syndesmophytes (at corners with at least 1 at baseline) or ΔmSASSS-score/year ≥1 unit/year. Hip involvement was assessed radiographically as mean baseline BASRI-hip score ≥2. The significance of changes was tested by mixed linear models for longitudinal data.

Results: Combination therapy with TNFi and NSAIDs received 100/262 (38%) patients. Indeed, more females (52/73, 71%) than males (110/189, 58%), (p=0.052) were under concomitant NSAIDs. New syndesmophytes occurred in 58% of patients in TNFi monotherapy vs. 36% of those in concomitant NSAIDs (p=0.001). Moreover, the ΔmSASSS-score/year was significantly higher in patients receiving only TNFi [0.7 (IQR:0.1;1.50], compared to those under combination therapy [0.1 (IQR:0;0.7], (p=0.0009).The mSASSS increased significantly both after 2.5±0.7 and 7±2.3 years of TNFi treatment. Nevertheless, the concomitant NSAIDs intake correlated negatively with the mSASSS (table 1). In patients with hip involvement at baseline, BASRI-hip score and MJSW did not change significantly during follow up (table 2). In those without baseline hip involvement, the BASRI-hip score remained unchanged after 2.5±0.7 years, but increased significantly compared to the baseline score after 7±2.3 years. The latter increase could be attributed to aging (b=0.007, CI:0.0006;0.01). In contrast, the MJSW did not change significantly during follow up (table 3). The NSAIDs co-administration had no effect on the evolution of both MJSW and BASRI-hip scores, irrespective of the baseline structural damage level (table 2 and 3).

Conclusion: Concomitant NSAIDs intake seems to have an inhibitory effect only on spinal radiographic progression but not on hip structural damage, compared to TNFi monotherapy in patients with r-axSpA. These different therapeutic outcomes could be attributed to the spinal osteoproliferative and peripheral osteodestructive changes, that occur in parallel in r-­axSpA. References1) Konsta M, Nurmohamed MT, Iliopoulos A et al. Prevalence and Radiographic Progression of Hip Involvement in Patients With Ankylosing Spondylitis Treated With Tumor Necrosis Factor Inhibitors. J Rheumatol. 2023;50:342-350

Longitudinal linear mixed-¬effect model to evaluate the time course of mSASSS

Longitudinal linear mixed-¬effect model to evaluate the time course of BASRI-hip score and Mean Joint Space width in patients with baseline hip involvement

Longitudinal linear mixed-¬effect model to evaluate the time course of BASRI-hip score and Mean Joint Space width in patients without baseline hip involvement

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/combination-of-tnf-inhibitors-and-nsaids-versus-tnf-inhibitors-alone-on-the-progression-of-structural-damage-in-the-spine-and-hip-a-retrospective-study-in-262-patients-with-radiographic-a/