5 Questions About Cardiovascular Risk and NSAID Use in Ankylosing Spondylitis

Nonsteroidal anti‐inflammatory drugs (NSAIDs) increase blood pressure and potential cardiovascular burden, but what is the association between NSAID use and incident hypertension in ankylosing spondylitis (AS)?

To answer this question, Jean Liew, MD, from the Division of Rheumatology at the University of Washington, and colleagues evaluated data of 628 patients with AS without hypertension who had either received treatment with continuous NSAIDs, noncontinuous NSAIDs, or no NSAIDs. Results showed that continuous NSAID use was associated with a 12% increased risk of developing incident hypertension compared with noncontinuous NSAID use or no NSAID use.

Rheumatology Consultant caught up with Dr Liew about the research.

Rheumatology Consultant: What prompted you to conduct the study?

Jean Liew: Hypertension is a major independent risk factor for cardiovascular disease and events such as myocardial infarction or stroke. Hypertension is common among persons with AS, and the prevalence of this comorbidity in studies of AS is about 30%. Age and gender distribution in those studies is important, and it has been previously shown that hypertension is more common among those with AS when compared with the general population after those factors are accounted for. We also have data connecting the use of NSAIDs with increased blood pressure and increased cardiovascular events, although this likely depends on cyclooxygenase-2 selectivity. NSAIDs are the first-line pharmacologic therapy for the management of AS. We wanted to answer the question, “Is continuous NSAID use associated with an increased risk of developing new hypertension in people with AS compared with noncontinuous NSAID use or no NSAID use?”

RHEUM CON: What is the most important finding from your study?

JL: Continuous NSAID use, compared with noncontinuous or no NSAID use, was associated with a modest but significant increased risk of developing new hypertension in people with AS, after controlling for other factors. The hazard ratio was 1.12 for incident hypertension (95% CI, 1.04-1.20) among patients who received continuous NSAIDs for AS. The association was not different among subgroups defined by age, body mass index, biologic use, or disease activity.

RHEUM CON: What should a rheumatologist keep in mind when a patient with AS is receiving treatment with a NSAID?

JL: This is a study of association, and the risk of hypertension was modest, so I would caution clinicians against using these results to recommend stopping NSAID treatment as a general measure. We also did not look at whether this increased risk of hypertension translates to an increased risk of cardiovascular events. There are other studies that have suggested that NSAID use might actually be protective against myocardial infarction or stroke in persons with AS. Given all of this, and the fact that there are still limited medications in our armamentarium for AS, I would focus on discussing the risks of NSAID therapy with patients. I would also suggest being vigilant about screening for cardiovascular risk factors, including hypertension, and making sure that these conditions are treated in conjunction with primary care.

RHEUM CON: Do you think biological medications can increase the risk of hypertension?

JL: I would expect that biologics, including tumor necrosis factor (TNF) inhibitors, would decrease cardiovascular risk and events. In our study, TNF inhibitor use had a nonsignificant trend that was in the direction of having an increased risk of hypertension. However, I would be cautious of this interpretation, as well, because the study was not designed to answer this specific question. I plan to conduct further studies that will address this.

RHEUM CON: What are the next steps of your research?

JL: I am interested in looking at the impact of TNF inhibitor use on cardiovascular risk factors and events in individuals with AS. I will use causal inference modeling, a more advanced methodology, to address these questions. I am also interested in the relationship between body mass index and AS disease activity over time.

For more on AS, visit the Resource Center.

Reference:

Liew JW, Ward MM, Reveille JD, et al. Nonsteroidal anti-inflammatory drug use is associated with incident hypertension in ankylosing spondylitis [published online September 17, 2019]. Arthritis Care Res (Hoboken). doi:10.1002/acr.24070.